What's the Trouble?

How doctors think.

by Jerome Groopman

On a spring afternoon several years ago, Evan McKinley was hiking in the woods near Halifax, Nova Scotia, when he felt a sharp pain in his chest. McKinley (a pseudonym) was a forest ranger in his early forties, trim and extremely fit. He had felt discomfort in his chest for several days, but this was more severe: it hurt each time he took a breath. McKinley slowly made his way through the woods to a shed that housed his office, where he sat and waited for the pain to pass. He frequently carried heavy packs on his back and was used to muscle aches, but this pain felt different. He decided to see a doctor.

Pat Croskerry was the physician in charge in the emergency room at Dartmouth General Hospital, near Halifax, that day. He listened intently as McKinley described his symptoms. He noted that McKinley was a muscular man; that his face was ruddy, as would be expected of someone who spent most of his day outdoors; and that he was not sweating. (Perspiration can be a sign of cardiac distress.) McKinley told him that the pain was in the center of his chest, and that it had not spread into his arms, neck, or back. He told Croskerry that he had never smoked or been overweight; had no family history of heart attack, stroke, or diabetes; and was under no particular stress. His family life was fine, McKinley said, and he loved his job.

Croskerry checked McKinley's blood pressure, which was normal, and his pulse, which was sixty and regular—typical for an athletic man. Croskerry listened to McKinley's lungs and heart, but detected no abnormalities. When he pressed on the spot between McKinley's ribs and breastbone, McKinley felt no pain. There was no swelling or tenderness in his calves or thighs. Finally, the doctor ordered an electrocardiogram, a chest X-ray, and blood tests to measure McKinley's cardiac enzymes. (Abnormal levels of cardiac enzymes indicate damage to the heart.) As Croskerry expected, the results of all the tests were normal. "I'm not at all worried about your chest pain," Croskerry told McKinley, before sending him home. "You probably overexerted yourself in the field and strained a muscle. My suspicion that this is coming from your heart is about zero."

http://www.newyorker.com/reporting/2007/01/29/070129fa_fact_groopman?printable=true