EM Collective Wisdom: Matthew Pirotte

Author: Matthew Pirotte, MD, FACEP (@MJP_MD, Assistant Residency Director, Assistant Professor, Northwestern Medicine/Feinberg School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

1) Why still Emergency Medicine?

Finishing up six years out of residency, I still genuinely love my job. I have a particularly rewarding practice environment with a combination of fantastic residents, an excellent center, great staff, and a challenging case mix. I have yet to get tired of trying to bring order to the chaos.

2) Most impactful case. 

It would be easy to find some critically ill patient where I thought I saved a life, but honestly when I reflect back I have to consider the time I completely lost my temper at work. I was just a few months out of training and covering a community hospital affiliated with my first gig. The patient was a young healthy guy who had a terrible influenza pneumonia and was in respiratory failure. The place was a challenging environment especially for a new doc, I was nervous about the intubation, had very little back-up, and it was a high-stakes situation.

I wanted the respiratory technician to go easy on bagging the patient because I was really worried about aspiration as the patient had been gasping for air for quite a while. The RT would not stop aggressively bagging, and in the moment, my fear and lack of confidence got the better of me and I absolutely blew my top – as in shouting at the top of my lungs, completely pulling rank, and basically being a complete jerk. Fortunately, the tube went in. The RT promptly and appropriately reported me to HR.

There was quite a bit of fallout. Even the nurses with whom I had good relationships told me I was completely out of line. My boss was fortunately supportive, probably more so than I strictly deserved. I learned a lot from that case, mostly about self-control and the damage a leader does to him/herself when he/she acts like a jerk. I do everything I can now to be easy to work with and keep Dr. Hyde under wraps.

3) Most important career decision leading to satisfaction.

I would say there is a tie here for me.

The first is really pushing myself to learn and practice at the full scope of my specialty. During training, but also in my early years as faculty, I really tried to learn as much as I could about procedures and interventions that might be things that would lead other doctors to consult. Because of this work I am able to do most of what an EM doc can do at work and I really enjoy teaching residents and students about things like fracture reductions, awake intubation, pleural procedures, PTAs, priapism drainage, occipital nerve blocks, etc. I try not to call for help unless I really need it or patient safety really demands it.

The second is beginning as a resident and continuing now to learn about personal finance. The White Coat Investor has been an invaluable resource for me in this area. Knowing my financial goals and understanding something about how money works has kept me from getting into a situation where my money stresses me out.

4) What does future of EM look like?

Lots and lots of more care coordination being done in the ED. I think the concepts of the soft social admit and the “admit them and let medicine sort it out” case are going to become things of the past. We are going to have to be better and better at integrating lots of collaborative teams to find the absolute best dispositions for patients.

I also tend to think we are at a technological inflection point in medicine. We have had things like computerized order entry and EMR for well over a decade now, but you could argue that neither of these has really revolutionized patient care. At some point things like machine learning, monoclonal therapies, and rapid PCR tests for bacteremia are going to revolutionize the empiric approach that EM often demands. I often reflect that at the end of my career, I will be telling incredulous medical students that we used to use prednisone for all sorts of inflammatory conditions instead of infusions of pharmacogenetically tailored inflammatory modulators and how we used to hit patients with empiric vancomycin and piperacillin/tazobactam because we didn’t know the exact bug in their system for several days.

5) Greatest achievement / why giving back is important.

Recently I heard from a student of color who struggled in medical school that I was one of the faculty members who made him feel a little bit more welcome and accepted during his tough times. I’d take stuff like that over a teaching award any day of the week.

We all remember how crummy med school and residency can be. It’s amazing how far you can get as an educator just by remembering how much it sucked to be standing there in a short white coat and not know the drill. Just remember that and you are going to be a pretty effective educator. It’s amazing to me how few faculty even ask students where they are from, where they went to college, and simple questions about their lives.

6) Favorite failure.

Wow, so many to choose from here. The possibilities are endless. I am not sure it’s exactly a crashing failure, but my current group of partners really keeps me on my toes. They are a great group of clinicians, educators, and researchers. I am constantly schooled and humbled by them in a thousand great ways, and I always feel like I am running to catch up.

7) One thing you would change about our field.

I really do not like the way that our nurses and staff are constantly subjected to abuse from patients. The data on assault on ED nurses is really shocking. I completely understand we are seeing people on their worst day(s), but that really does not excuse the way that many people in the ED act towards the staff. We end up using humor to process the constant string of abuse, but really when you think about it, it is not funny. I think our willingness to take this should drop by a lot. If you ask around, many nurses and techs feel that quite a few docs do a bad job “having their backs” with abusive patients.

8) Something that you love that has indirectly impacted your EM career.

I know it would be a common response to this type of question, but my daughter was born last year, and everyone who said it before is totally right – it makes you 10x better at pediatrics. I completely understand the frazzled mom bringing her kid in at 3am with a URI now. My chairman in residency gave us a pearl about dealing with peds cases that has kept me in good stead: constantly compliment the parents as you counsel them. “You’re doing a great job, he is looking really well cared for,” is the type of phrase that struggling parents need to hear. I also learned a lot about all of the crazy things neonates do that seem like harbingers of critical illness but are really completely normal. Nine months into being a dad, I have absolutely no idea how humans evolved to our current planetary hegemony: our offspring seem designed to try to injure themselves in every way possible.

3 people you’d like to see fill this out

1) Jeremy Boyd

2) Mark Cichon

3) Andrew Pirotte

4) James Dahle

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