GUT FEELING

      We often talk about evidence based medicine. I am in practice for many years  and I can tell that in medicine many a times we make decisions based on GUT FEELING. The medical societies often talk about this as clear cut and the people in Ivory Tower of medicine have no understanding as to how in medicine we have to make a decision.In my mind current COVID treatment is in same situation. When I looked at it last more than 20 different treatments were tried  and some with claimed success. One example is Hydroxychloroquine. But I am not talking about COVID in this article. 

   I saw this 72 years old lady many years ago and she had been smoker and she had COPD , She was seen and followed by her PCP  and she  when she had chest X- ray  and that was abnormal she was sent to hospital. We did the work up and she had advanced COPD due to smoking - the damage that happens due to smoking  and she needed oxygen 24/7  and she also had a cavity in the upper lobe  and that happened to be atypical TB . I started her on medicines for COPD  and oxygen and also treatment for the MAC or atypical TB. She did well and she improved  and I did see her for about a year. Her CT scan showed improvement  and she had no new complaints . She then was admitted with shortness of breath and so she was in hospital. I saw her, As expected she was admitted as COPD WORSENING. I had hard time believing that she had COPD worsening  and I was worried that this time it may be heart. So I did a ultrasound of the heart - echo cardiogram. It showed that her heart function was reduced.So I went with my GUT FEELING and that was correct at least I thought I was . We did treat her for both- COPD  and HEART PROBLEM  and she did improve. She was discharged. But before she was sent home, she had seen a cardiologist and she had stress test  and that was normal. 

    She did OK  and then she had an episode of shortness of breath that woke her up  and she was in ER  and as expected the ER physician told the family that she has pneumonia. She had no fever and the episode was somewhat sudden. She had no history suggestive of respiratory infection - not much cough and no sputum and the white cell count was normal. The chest X- ray did show some infiltrates or congestion. Knowing the history , I decided to treat her for heart problem . When the heart does not pump blood out normally, then the water backs up in lungs  and the Lungs which are like dry sponge becomes like sponge filled with water and then patient can not breath as the lungs are heavy. So I started her on water pill and she did improve in less than 24 hrs. The stress test had shown normal heart function, but in my GUT FEELING on both occasions this was HEART  and not LUNGS as the cause of her problems and the evidence based medicine would have suggested this as was COPD  and not heart problem. So I often respect Gut Feeling . By the way I did give her antibiotics for 2 days till I was sure that she had congestive heart failure.