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Little White Coats

Welcome to Little White Coats!
Little White Coats is the brainchild of Richard M. Pescatore II, DO, the chief resident in the emergency medicine program at Cooper University Hospital in Camden, NJ. He is a 2014 graduate of the Philadelphia College of Osteopathic Medicine. Follow him here as he finishes his residency.

Dr. Pescatore has served as an EMS and law enforcement medical director and advisor throughout New Jersey and 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.

Tuesday, August 9, 2016

I've thought about mentorship a lot recently. After four years of medical school and two more in residency, I've had the opportunity to meet dozens of teachers, guides, and tutors who have served as role models and sounding boards. There were the senior students and junior residents who showed me a clinical light at the end of a long didactic tunnel in medical school, just as now freshly minted attendings tell me tales of full nights of sleep and entire weekends away from the hospital.

More than a handful of nurses helped me grow into the doctor I am now, reliably present after a difficult case with their years of experience helping to draw perspective or lend objectivity when emotions ruled the moment. The list stretches on, with so many mentors likely never realizing their daily impact — a senior resident with a son who served as reassurance that I could survive having a baby in residency, colleagues with such dedication to wellness and healthy living that I couldn't help adopting some of their habits.

And the more I think about it, the more I marvel at how much of my journey has been guided by those who I never stopped to recognize. How could I, really? Only years later can I see that the calm confidence of my corpsman Chief Petty Officer would lead me to medical school or that a flippant admonition from a surgical resident about the importance of self-education would start me on a career rooted in evidence-based medicine. So often we model ourselves based on the examples set by those around us.

Dr. W probably doesn't know how much her perpetually sunny disposition sets an example for optimism, just as Nurse S is simply doing his job, unaware that his compassion for even the most routine cases reminds all around him of the special roles we play. Through their dedication to patients and our profession, it's people like this who unwittingly provide reassurance and guidance to all who surround them.

​As I've advanced through the years of residency, I like to think that I now fill a mentorship role like so many others before me. Whether it is for our rotating medical students, eager young researchers, or even the newest wave of interns to hit the hospital doors, I hope that the standards I set and actions I take are as welcome and exemplary as the models set for me. I've already seen instances in which I've failed — allowing my biases against certain approaches, therapeutics, or thoughts to be portrayed as fact, letting a difficult shift interfere with an obligation to teach, or standing back as others learn their own way. But I beamed with pride recently when a learner harnessed our shared experience at his next patient encounter, and I smile whenever I see a championed cause being adopted by a colleague or student.

And, just as the proverb says, it seems that lighting the path for others always brightens one's own. The satisfaction of teaching, writing, and learning alongside the bright minds of emergency medicine is fulfilling and inspiring, and I quickly realized the importance of retaining that experience as I prepare to move on from residency. It was, natural, then, that I would look to home when the time came to plan for the years to come, toward the mentors and educators who started me on this incredible journey.

And so my career as an attending physician in academic emergency medicine will start back where everything else began, in my hometown of Vineland, NJ. For 30 years, I've watched with pride as Inspira Health Network has grown and developed, bringing ever-improving care to my family, friends, and neighbors. I couldn't be more excited to begin next July, serving as a residency educator and clinician alongside the men and women who taught me from the very start and serving the population closest to my heart.


Friday, June 3, 2016

It's 2:18 a.m. on my last trauma call of the year, and the Memorial Day celebrations seem to have started early. More than a few gunshots have echoed in the humid night, their victims brought in by screaming police cars or their own family's rusting minivan. On the other side of the trauma bay doors, the slurred screams of intoxicated revelers occasionally pierce the otherwise dull roar of our busy department. The end is in sight, and I'll again likely forego some sorely needed sleep in exchange for the moments with my daughter that seem to be passing faster than I ever expected.

Things seem to be falling into place. I once again look forward to every shift in the emergency department, and find enjoyment in the critical and the routine. It's exciting to see how far the interns have come, clearly now ready to take on the challenges of their second year, one that I definitely found more difficult than the first. Publication decisions have come and gone, removing some of the stress of uncertainty from the day, and once-nebulous career plans are coming more sharply into focus. Every day brings with it new opportunity and possibility.

Still, residency is difficult, and it's a lot tougher with a 5-month-old at home who demands attention and has an uneasy relationship with her crib. Before Eloise was born, a 4:30 wakeup would have meant time for a run or a trip to the gym. Now it's barely enough to get her to the babysitter and make it to the hospital on time. It breaks my heart to wake her from hard-won sleep and have to transfer her immediately to the car seat. All too often there are only a few seconds of wakefulness for me to steal before saying goodbye for the day. Desperate to enjoy every moment of these first months, it means that the baby accompanies me whenever possible. She has been to borough council meetings and spent her fair share of time in the hospital while I finish backlogged paperwork. I've snuck her alongside the treadmill at the gym, only to be subsequently tossed out by an irate employee.

So my goals have shifted, and with them my productivity has waned, or at least transformed. As an intern, I pumped out projects and manuscripts at a regular clip, a pace that is neither possible nor prudent as the final year of residency begins. Energy not spent on baby duty is poured into bedside and didactic education to strengthen the foundations of our younger learners. Instead of writing cover letters and reference sheets, I write post-shift emails and whiteboard cases. Perhaps the most compelling part of that adjustment is that it doesn't bother me. Before such a lull would have driven anxiety and angst, but now I seem to have found contentment with my new normal. The drive to prove oneself takes on a different meaning as a family grows.

​I am repeatedly fascinated by how so much of what makes an emergency physician is defined by pursuits outside of the department. Bedside compassion and clinical practice often seem driven by experiences personal and professional, just as extracurricular involvement is so frequently a consequence of passions learned inside the ED walls. The few months I've spent as a father have had a profound impact on my clinical practice and professional pursuits, with every patient encounter and each midday meeting held with an eye toward my family and our future. As summer begins and long days under fluorescent lights beckon, I look forward to engaging my final year with a hard-won realignment of priorities.


Tuesday, April 19, 2016

Years ago when I finished Plebe Summer — the training program required of all incoming freshmen to the United States Naval Academy — my grandfather presented me with what has become my most prized possession. It's valuable to me not just for its probable auction price and its unique place in history but for the incredible story behind it.

A young, first-generation Italian American, Frank Pescatore reacted like so many others to the events that took place on Dec. 7, 1941. He beat down the door of the U.S. Navy recruiter's office as the sun rose the morning after. Bags already packed, full of patriotism and indignation, and hair cropped low (a harbinger of alopecia to come, maybe?), my grandpa was eager to join the fleet and strike a blow for Uncle Sam. With the hard-won blessing of my great-grandmother, he shipped off for the accelerated boot camp the Navy had started. A tinkerer by habit, it was little surprise to anyone that Frank Pescatore was assigned to a naval construction battalion, the Seabees.

Grandpa plied up and down the Pacific as Admirals Chester Nimitz, William Halsey, Raymond Spruance, and Ernest King fought the world's greatest sea war against the Empire of the Rising Sun. Rising to the rank of Petty Officer, Second Class (the Navy's version of an Army Sergeant), he was lucky enough to have his own Jeep during the Battle of Okinawa and its aftermath. It was this simple privilege that brought me my prize and this story.

Sitting in his rusty Jeep one morning on some unnamed beach in Okinawa, an army intelligence officer — a captain to my grandfather's recollection — approached Petty Officer Pescatore. He gave a lazy salute, then tossed his dirty boots and weary feet back on the dash where they had been resting. "I need your Jeep, sailor," Grandpa remembers the young officer saying. My grandfather was less-than-compliant and continued his supine post. Another order from the officer, another chuckle from the enlisted man. Ultimately, the IO must have realized he was up against Italian stubbornness, and began to bargain. "What'll it take for you to give me that Jeep?"

And that's how I ended up with one of the original copies of the Japanese surrender on Okinawa. I have the urgent dispatches the officer had just carried away from the armistice table. Taking custody of the calligraphed parchment, Grandpa whipped out his own pen and scribbled a few words to his mother that put a poignant closing paragraph to his wartime adventure.

"As the bombs burst overhead and the guns fell silent, my heart turned toward you, Mom, back in the States. I will carry this paper with me for the rest of my life — for this document many a buddy of mine lies dead on Okinawa."

"They were the bravest men I ever knew," Grandpa added, a tear streaming down his palsied cheek that day in August when he handed me the yellowing scrolls.

As we laid my grandfather to rest yesterday, more than a few similar tears found their way down my own cheek. I remembered this story and thought about the many lessons this great man had taught me along the way.

What's the connection to this blog? To emergency medicine and my residency journey? I guess it's the perennial thought that our life stories are so often shaped in the moments we least expect, or by the daily grind we so rarely reflect upon. The second year of residency is nearing its close, and I'll start the next academic year just a little more experienced, a little wiser, and a lot more weary.

I'm tasked with the honor of chief resident, even though it feels like just moments since donning the long white coat for the first time. Even though those first days of intern year seem like just yesterday, it took a cold, rainy morning and a moment of mixed reflection to realize that there is no defining moment in store and no transformative event to prepare me for the year ahead.

​Every instant of residency so far has played its part in my own story, one I'm so fortunate to get to share here. Even as I said goodbye, my grandfather had left me one last lesson.


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.