16 October 2009

Oh please don't ask me that

I was camping not too long ago when my oldest son and I were lucky enough to see the most amazing shooting star I have ever seen in my life.  Not the one pictured above -- I didn't have a camera handy -- but it looked about the same.  (See the Bad Astronomer for the awesome backstory on the above picture.)  It was the coolest thing I have ever personally seen.  It lit up half the sky as it streaked across with the most incredible speed; it was brighter than any firework I have ever seen.  And in an instant, it was gone.  We continued to hang out by the campfire for a while, every so often reflexively looking back at the sector of the sky where the fireball had been, as if it might be there again.  It was certainly the most remarkable event of an eventful day.  As we walked back to the cabin, my son asked me a question that kids must have been asking their parents for millennia: "Dad, that shooting star was cool, but what did it mean?"

I explained that it didn't mean anything.  It was just a hunk of rock becoming superheated as it slammed into our atmosphere at thousands of miles per hour.  Ultra cool science-y explanation, but it clearly left him unsatisfied.  He was hoping for something more.  I could imagine in ages past how a father might make up a satisfying explanation regarding the anger of the gods, or an omen of good fortune, and how readily a prescientific community would accept such an explanation.  It was the most amazing event -- it just had to mean something.

I've noticed that this is just the way people are.  We have a deep seated need to look for patterns, to find the deeper meaning in things.  It's how we make our living, evolutionarily speaking.  We figure out how things work, find the causation, and exploit it to our advantage.  It's natural and a highly adaptive trait.

But it also is one that drives me nuts, in my professional life.  That terrible question -- "What does it mean?" -- is one that one that stops me in my tracks, raises my hackles and induces an involuntary inward cringe.

I see a lot of people who come to the ER after experiencing an unusual physiologic phenomenon.  Whether it's a fainting spell, or sudden loss of vision, or an intense bout of dizziness, they are often really freaked out.  I don't blame them.  I've experienced vertigo -- it's a shocking thing to go through.  Nothing in your experience prepares you for the feeling that the world is whipping around at 33-1/3 rpm.   I do my thing -- check them out, make them feel better, and explain the cause in as much detail as seems appropriate.   Generally, patients are grateful and receptive, especially once I've reassured them that what they are experiencing is not dangerous.   It never seems to fail, though, that as I put my hand on the proverbial doorknob to step out, I get that awful question, "But doctor, what does it mean?"  Just like the fiery streak across the sky, when it happens to you it's such a remarkable thing that it simply has to have some deeper meaning.

This question is an absolute rhetorical haymaker because, just as with my son and the technical explanation of a meteor, the technical explanation of vertigo (or syncope, a TIA, etc) is completely unsatisfactory to the patient.  Unlike a seven year-old child, however, the patients are adults, infinitely more concerned, and I have something of an obligation to answer their concerns.  And it just can't be done.  99% of the time the answer to "what does it mean?" boils down to either "I really have no clue what actually happened" or "it's just one of those things."  You can guess how well that goes over.  You offer up such weak tea to an anxious patient and you are either guaranteed an irritated and unsatisfied patient, or a thirty-minute question-and-answer session till they're finally content.

I've learned that the best response is a redirect: "You know, the ER's not really the best place for philosophy..." and then to bring it right back to the pragmatic concerns: "What it doesn't mean is that you are at increased risk for having a stroke..." or whatever seems to be the real underlying fear the patient may have been harboring.  That seems to work as well as any other response I've tried.

Every time I hear that question, I swear it takes years off of my life.


  1. I'm piloting this at the moment: whatever question my kids ask for which I have no immediate, definitive answer, I truthfully respond "I have no idea what/ who/ why/ where/ when" (etc. etc. I'm sure you get the picture.) followed by "But the internet's full of really useful information, and I'd love for you to find out what/ who/ why/ where/ when (etc. etc.) and then you can come tell me what I don't know.

    Course, that might not be such a good thing to tell patients... just sayin'

  2. "Does this need to mean something?"

    Maybe better: "Do you want this to mean something?"

  3. Oh dear, SF, I don't buy this at all. You're a writer, among other things, and writers naturally see and feel the metaphor in everything, so enough already with the Gawd, how I hate things that depart from hard science whining.

    One needn't fall for twenty kinds of superstitions or religions (same thing?) to note the synchronicities of the universe, of nature, of our own bodies.

    As such, when my boys asked me what a meteor was, I gave them the proper, correct answer--chunk of rock, bursting into flames, etc.--but I also told them how such unusual and beautiful occurrences should give us all pause, should make us remember that each of us is just one of billions of human animals living on this single rotating rock among countless planets in similar systems, and the universe is so much bigger than that--with so much going on to be curious about and awestruck by--and doesn't this make you feel silly for getting so upset about that snotty-nosed Pierce calling you a douchebag in Algebra?

    And obviously I'd never be in a position where a hospital patient would ask me for advice, but if he or she did wonder about the meaning of a vertigo episode, to use your example, I'd probably give the proper, correct answer and then, if that didn't seem to satisfy, I'd offer something like, Well, one useful interpretation of that vertigo episode might be that it's a reminder that we're human beings living in this busy world, not machines; and that it's important to pay attention to ourselves--to sleep well, eat well, get enough exercise, and generally put our needs first sometimes, because doing those things makes us healthier overall. Therein, you've given your patient a wonderful gift: permission to be a bit selfish and look after himself. (Can you tell I'm a mother?)

    What does Van Gogh's Starry Night mean? Sure, it's mixtures of Cobalt Blue and ochres and umbres and Lamp Black and linseed oil spread across a piece of stretched cloth in a pleasing pattern. And it isn't even all that large a piece of cloth.

    But the painting means so much more, don't you agree? It's torment, and wonder, and loneliness, and fear, and looking at it gives you an overarching sense of the artist's feelings of insignificance and despair amid a vast and roiling universe. It's all those things, and many more, especially: permission to be selfish and introspective for a fleeting moment; invitation to pause and let the rare colors of a monumental event wash over you, as with the shooting star, as with the birth of a child.

  4. Or is Starry Night a symptom of a disease, that still inspires speculation?

    Vincent van Gogh's medical condition

  5. Wow, Rogue Medic, I knew about the speculated bipolar (which seems kind of obvious, in retrospect). As for the lead poisoning and sunstroke, those were common maladies of the time, with lead being a component of various paints, as well as numerous grooming aids and common household substances (for starters). I don't think people were terribly aware of the sun's ability to wreak havoc, either--certainly sunscreens for fair-skinned folks weren't yet on the market.

    It's also kind of a given that Van Gogh drank a lot. Lots of people, nay, almost everyone did in those days--several of my great-great relatives died of cirrosis-- but how many people painted like Van Gogh?

    If he was exposed to a lot of mercury vapor (used in hat-making and fabric sizing back then), turpentine, and other toxic substances, the excessive drinking and thujone (absinthe) ingestion on top of that might have brought on all those seizures. I'm guessing there were no EEG's back then (late 1800's) to confirm a diagnosis of epilepsy.

    I submit that bipolar was the steering mechanism for all the above--the reckless sun exposure, the self-medicating, the erratic behavior. Most saliently, it was the condition that, during his manias, allowed him to walk with the gods, however temporarily, and share his experiences through paint.


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