Internecine

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.