The aim of this article is to elucidate the complexity of internal crisis communication by identifying and discussing different paradoxical tensions embedded within a large, complex, multi-professional organization. This article is based on a qualitative case study of a university hospital. Internal dimensions of crisis management have long been neglected within the field of crisis communication research. In the first part of the article, two theoretical approaches are presented – the functionalist and social constructionist which are based on different ontological and epistemological assumptions. We take a social constructionist perspective on crisis communication, which focuses on aspects such as complexity, sensemaking, and symmetrical relations. In the first part, we also give a brief overview of the small, but growing research into internal crisis communication. In the second part of the article, five different paradoxical tensions are identified and discussed: (1) episodic–emergent, (2) centralized–decentralized, (3) professional–organizational, (4) planning–improvisation, and (5) external–internal. While the complexity of internal crisis communication demands a both-and perspective, we have found a tendency to a simplistic either-or thinking. In the concluding discussions, several explanations of the one-sided polarization within the tensions are offered. Furthermore, we discuss various ways of responding to paradoxical tensions. Metacommunication is presented as important in order to increase organization members’ understanding and thereby facilitate a more reflexive and broader approach to crisis management.