Wednesday, August 08, 2007


Late last month, Sri Lankan police killed 12 members of the Tamil Tigers, a rebel group with which they have been fighting for nearly 25 years. At issue is self determination for two rival groups sharing a small island with limited resources.

It is easy to see how this is like a hospital. Within the four walls (figuratively speaking, since my hospital was built in about 50 different stages and has long since ceased to be rectangular) of this building are numerous warring tribes, calling themselves internists, surgeons, pediatricians, radiologists, and the like. Through the vicious coming of age ceremonies involved with these tribes, they come to identify all outsiders as unclean, beneath their attention, untouchable. What makes this caste system more complicated than the politics behind Alexios I Komnenos' hold on the throne of Byzantium is the fact that no one group recognizes an ultimate ruler, and no one group is treated equally badly.

Surgeons, for example, tend to look down on internists as nitpicking, reactionary types overly concerned about minor lab values, most of whose conclusions need to be regarded with considerable skepticism. Even nice, earnest surgeons can fall into this category at times. Internists, for their part, are generally frustrated with surgeon's apparent disregard for important but small lab values and seeming inability to document more than the most obvious one or two physical findings, usually in cryptic, barely legible acronyms, but we reserve our most earnest hatred for ER physicians.

Surgeons, we reason, have an area of expertise beyond our ken, and we beyond theirs. I, for one, will never presume to take out an appendix or a liver, just as I wouldn't expect a surgeon to handle renal tubular acidosis or manage diabetes. We only step on each other's toes in presuming outside our area of expertise, and both our specialties can complement one another. An ER physician on the other hand, oftentimes appears to be actively involved in undermining our patient's health. For instance, I recently admitted a patient with atrial fibrillation causing a rapid heart beat. The ER physician though, assumed this was due to alcohol withdrawal, so despite reading the patient's old notes, he started the guy on a Versed drip rather than a diltiazem one. As a result, the patient got more and more somnolent and had to be intubated. Fortunately my resident and I got to him in time to start a medication that would actually treat his condition and prevent damage to his heart.

What gets lost in the griping as the tribes head back to camp to prepare more war paint and weapons is the fact that, even if we aren't shooting radiologists like Tamil Tigers, real people can be hurt in these conflicts. The ER, for example, does see acute alcohol withdrawal, and they did a)realize this was a bit atypical and b) call me before it got out of hand. I'm sure many times they would have been right with the Versed. So despite recognizing my growing attachment to my tribe, and my earnest defense of it in the call room, I'm trying to remember also that most of us have the patient in mind, most of the time. Sri Lanka I can't help. Bed five in the ED? I'll be right down, and sure, I'll consider alcohol withdrawal.


Anonymous said...

what a vivid and apt description of the world of the hospital!


Nathan said...

Thanks. And I forgot to mention, part of what began to drive this home for me is the "wall of shame." One entire wall of the resident call room on the cardiology floor is dedicated to photocopies of ER notes containing the more humorous "flashes of brilliance" we've observed, collectively, over the past ten years or so. Illuminating, scary, or funny, take your pick.

Anonymous said...

oh, these would be worth seeing!!! all anonymous, of course!


Matthew said...

Just from a psych perspective, Versed drip??? As opposed to 1-2 mg Ativan po Q4 hours prn elevated blood pressure or tremors while you wait for the psych or medicine team to institute a formal Librium or Ativan taper? Are they seriously putting drunks on DRIPS there? Man.

Our consult service is the one with the most issues with the other specialties. We get a lot of medicine consults saying, essentially, "We just told the patient he has terminal cancer. He is now crying. Make him stop." But then, I also call medicine for blood pressure concerns on my patients that turn out to be nothing. Or I have patients who fake chest pain, and I still have to call the medicine people, which sucks.

Nathan said...

Yes, Versed drip. To his credit(?) the ER resident was switching the guy to Ativan when we got there, but it hadn't started.

I'll also admit I'm laughing at the "he is now crying. Make him stop" line. And that I've been told to write it. But I try to pull out one of the five or so things I retained from my psych rotation and tell my resident that the guy just has "adjustment disorder with depressed mood" and we may not need psych. Usually the resident comes back with "type, computer monkey. You are the intern." I apologize for my medicine brethren over there.

Alice said...

Oh yes, the psych consult. Unfortunately, we have a patient like that right now. I was flipping through his chart, adding up the lab levels which equal liver failure within a month, and came across the notation, "psych consult: terminal diagnosis." In a way, it might not be a bad thing. We have to admit that psychiatrists probably do a better job of holding people's hands through a tough time than most physicians. The rest of us stand there talking about what we might be able to do to make things a little better for a little longer. . . and the patient never gets a word in edgewise.

I'll tell you two tribes I recently realized get along: GI and surgery. We almost love each other; we refer constantly, and we mostly respect each other's opinion.

Anonymous said...

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Anonymous said...

Good point, though sometimes it's hard to arrive to definite conclusions

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