Doctored by Sandeep Jauhar Page B

pressure could be overwhelming at times because mistakes often had huge consequences, and fear of malpractice—and the resulting lawsuit—were lurking just under the surface of most of my and my colleagues’ dealings with patients. One morning I got a call from the emergency room. A young man—an intern, in fact, who had been on rounds on the wards—had been admitted with chest pains. Could I come to evaluate him?
    The ER that morning was the usual mess of drunks, druggies, and demented old ladies pretending to read The New Yorker . There were the usual pressured announcements overhead (“Linda, stat to the trauma bay … Linda”). Stretchers were arranged like latticework in the corridors, and the air was suffused with stale body odor. Searching for my patient, I ran into Joe Ricci, a jovial cardiologist who practiced in Howard Beach. Ricci was always impeccably dressed and, unlike most private practice doctors, never looked as if he was in a hurry. “How are things?” he said pleasantly. “Getting used to the place?”
    I said I was. In fact, I was quite enjoying my work and was finally starting to feel confident. Ricci brought up a mutual patient. “Sarah Brenner is doing very well,” he said. “I guess those drugs you’re pushing really do something.” I laughed. “By the way,” he said conspiratorially, “did you see the article in the Times about how doctors should work on Sundays? Ridiculous, isn’t it? They think we’re selling shoes.”
    When I found the intern, Zahid Talwar, he was sitting on the side of a gurney, legs dangling, looking bored. He was about thirty years old, a Pakistani man with a long face and a white coat who straightened up respectfully when I arrived. I introduced myself and asked him about the chest pain. It had started after dinner the night before and had lasted about ten minutes. He had slept comfortably, but the pain recurred while he was walking to the bus stop that morning, persisting for almost an hour. It was a dense pressure in the center of his chest. To be on the safe side, he had decided to leave rounds and come to the ER.
    His blood tests were normal, as was his first electrocardiogram. He had none of the traditional risk factors for heart disease, such as diabetes, hypertension, or a regular smoking habit. I suspected he was suffering from acute pericarditis, a usually benign inflammation of the membrane around the heart often treated with over-the-counter anti-inflammatory drugs. Characteristic of pericarditis, the pain worsened when he took a deep breath. I told him that if blood tests in six hours were normal, we would send him home. I joked there were easier ways to get out of internship duty.
    Later that morning I got a call from an ER physician informing me that my patient’s pain had resolved completely after he had taken ibuprofen, further confirming the diagnosis of pericarditis. For a moment I considered sending him home right then, but I decided to wait until the next set of blood tests was complete.
    Just before leaving the hospital that evening, I ran into a physician’s assistant. He told me that Zahid’s subsequent blood tests showed evidence of minor cardiac muscle damage. This took me by surprise. Pericarditis usually does not result in abnormal cardiac enzyme levels. I quickly explained that the problem was probably myo pericarditis, in which inflammation of the surrounding membrane can partially involve the heart muscle. He asked me if the young doctor should have a cardiac catheterization to rule out coronary blockages. It was late; I told him that any workup could wait until morning. I assured him that a thirty-year-old with no risk factors did not have coronary artery disease. I instructed him to draw more enzymes and to order an echocardiogram and call me at home if there were problems.
    Zahid had chest pains through the night. Doctors who were called to see