Where The Hell Do I Start?

When you show up on the hospital door steps from an outside ER at 1am with the following problem list

• hypotension causes unknown
  
• altered mental status
• reported "TIA" type symptoms
• hypoxemia on 4 liters of oxygen
• recent pacemaker placement for asystolic pause/Sick Sinus syndrome
• afib on anticoagulation
• dilated loops of colon of uncertain etiology
• abdominal pain
• RN reported lower GI bleed with "clots"
• end stage renal disease on hemodialysis
• right basilar infiltrate on chest xray
• recent "enterococcus" sepsis
• cardiomegally
• large ventral wall abdominal hernia
• anemia

You had better hope there is a hospitalist doctor there to greet you. I think to myself

1. Without a hospitalist, who would accept this patient on transfer?
2. Without an in house hospitalist, would this patient really get a bed side evaluation for every one of their medical issues, in real time, that night?
3. With all the hype about extenders, how would a NP or PA handle this type of admission?

As I learned in medical school and residency, caring for these types of patients requires a fundamental ability to break down each and every problem into its own little box. To be looked at and dissected independently of all the noise surrounding it. Once you understand the state of each condition alone, only then are you allowed to open that box and share its contents with the other 20 boxes stacked up all around it. Each box boldly claiming that they are the most important issue at hand.
I was not comfortable with this concept until well into the third year of my internal medicine residency. Most PA's and NP's can handle one box. As witnessed by the onslaught of extenders flocking to specialist care. All of our procedural oriented specialists in my community have extenders that write the daily notes for all my patients. You know, the lower paying (relative to procedural pay) E & M cognitive codes. A few words jotted here and there by the doc completes the E&M process in nary a minute.
But I shudder to think of how an extender would respond to this type of complex multiorgan failure scenario when plopped on their lap at 1 am. And this is the norm of hospitalist medicine, not the exception. I remember my internal medicine rotation as a 3rd year medical student. I remember being overwhelmed beyond all imaginable means. "Where the hell do I start?" was the only constant in that 12 week experiment that taught me how little I really knew.
Sometimes, that thought still crosses my mind. But the disorganized fear of my med school days is gone. Replaced with a confident, capable expert in my skill set. I'll be the first to admit, however, that doesn't include femur fractures.