Читать книгу Concussion - Kester J Nedd DO - Страница 18
ОглавлениеWake up America and Wake up World!
I HAVE HEARD and read with interest the Story of Benet Omalu; the Nigerian born neuropathologist who has popularized the term chronic traumatic encephalopathy (CTE). As a victim of the traditional approach to medical care, medical systems, and medical research, his story has become a catalyst for all to wake up and take note. This wake-up call is for the medical community, sports organizations such as the NFL, and the field of brain injury. In his book Truth has no sides, he tells the story of how a not-so-well-known neuropathologist lost his job and was asked to recant a landmark paper on the subject of CTE that he published in the Journal of Neurosurgery. The story describes the finding of CTE in a famous NFL player, Mike Webster who was featured in the movie, “Concussion.” Dr. Omalu fell prey to criticism by the institution of one of America’s favorite pastimes, American football. He took a position that made the parents of our kids stand up and take notice, exposing the short-and long-term impacts of injuries suffered in contact sports. His point about not allowing children to play contact sports such as football before the age of 18 resonates with me. In my role as a physician who often takes care of children, I am constantly asked this question: Would you allow your kid to play American football or, for that matter, contact sports? The real issue here is science! Irrespective of what side you are on, and yes, there are sides, this concern must be addressed in our society.
At a recent survey of neurologists, performed at the Texas Neurological Society’s 20th Annual Winter Conference in 2017, the question “would you allow your son or grandson to play American football?” was asked. Well, guess what the answer of most neurologists was. A resounding NO! (Evans 2018).
If you are driving a car in America and not wearing a seat belt, the police can stop you and give you a ticket. You are actually more likely to suffer a concussion in a game of American football than you are driving a car, if you measure game on game vs getting in your vehicle each day. An entire sector of the automotive industry has been built around this issue of safety. Despite the risk associated with driving, people still drive because it is a necessity. So, let us ask ourselves a question: Are contact sports necessary in our society?
Like Dr. Omalu, I came to America from a small island nation called Grenada in the Caribbean, otherwise known of the island of spice. I did not grow up playing football, and the sport was completely new to me when I arrived in America in 1975. I too had concerns about the hits I witnessed during games. My introduction to concussion occurred when I was attending medical school in Kansas City, Missouri, at the University of Medicine and Bioscience. I had volunteered as a second-year medical student to examine youth involved in an organization called “Golden Gloves.” This was a boxing movement that helped disadvantaged kids and even those not so disadvantaged. It was the kind of program that kept youths off the streets, while actually helping them to build character and a future. Despite wearing head and face gear, we saw knockouts, concussions, and on one occasion a more severe injury that resulted in a youth being hospitalized. Even for teenagers, the hits were palpable. You could literally feel a vibration in the air when some of the punches landed. Just following the career of Muhammad Ali and his subsequent development of what is believed to be pugilistic dementia and then Parkinson’s helped shape my opinions. As a neuroscientist, I was forced to hook my wagon to the issue of brain injury, its consequences, and the subsequent treatment and recovery. From the time I started in the field, it took approximately two and a half decades from my first interaction with this issue to this point where the industry now recognizes the connection between concussion and sports. Yet, compared to strokes, multiple sclerosis, and cancer, from a human manpower and resource standpoint, the allocation of financial capital and devotion to this cause remains in its infancy. The question here is “why.” More importantly, the second question is “what can be done about it.”
Let’s first deal with the question of why.
20:20 hindsight. We can all learn from the experiences of the past, and there is plenty of blame to go around. Now, many of you reading this book may have “an ax to grind” for whatever reason. I truly like the title of Dr. Omalu’s book The Truth has no Sides. But, for most of the stakeholders out there, it does have a side. This issue pertaining to sports in America is very complex, and while I do not have all of the answers, I will attempt to do my best to address them one by one. I know that I may get a lot of flak for even bringing up these issues, but so be it.
In the book so far, I have been touching on the issues of concussion and TBI, in a way linking the issues to the challenges at hand. Bringing it all together is really what can move the needle and provide an overall picture of what we are facing.
When I came to America, a history professor in college once said to me that if I wanted a thing to attract attention, belonging to one or more of the following categories might be helpful:
• Either be rich or involved with someone rich and powerful or belong to a social class of the privileged;
• Have political clout;
• Be articulate and have the ability to recruit followers;
• Have an interesting story, not just a rag to riches.
Of course, some of this has changed with the advent of the internet and social media where the story of an “off-the-beaten-path Joe Blow” can raise awareness and call for attention. The world has now changed, and traditionalists are even left behind at times.
So, here is the wake-up call. Consumers are the ones writing the script simply by the questions they ask. In my years working as a medical professional, I must admit, I see a tremendous difference in the way men and women handle the issue of concussion and TBI. I see women – mothers and grandmothers – at the center of this discussion. Here is a page from my experience. Together with my colleagues at the University of Miami Sports Medicine program and formerly at Jackson Memorial Ryder Trauma Center, I have been following high school, college, and professional athletes and trauma victims with concussions and TBI for over three decades. The truth is that there has not been a time that this issue was not brought up. I was speaking to a trainer at one of the high schools when he made the most profound statement about this issue, one I still carry with me to the exam room. He said, “It is the mothers and the grandmothers that are changing the face of the game.” Industry, the NFL, the NHL, the NBA, and all of the sports organizations out there, please take note because, in the next decade, the face of the game will change. I can feel this change out there as a clinician. Ask people at the Academy of Neurology what some of the most important reasons for being consulted are. Ask the pediatricians about what is being said and what families are concerned about. There is a groundswell occurring, and it has gone worldwide. We cannot stop it now. Check online social media and commentators out there, and well, the amount of attention that TBI/concussion receives is alarming. TBIs and concussions have not been a “sexy issue” until now. It’s been for years “kept under the rug,” but no more! Here are some of the reasons for which it has not received this much attention in the past:
• The treatment of TBI and concussion did not have the characteristic of a drug in development, which can produce huge revenues for a pharma company. So, companies such as “Big Pharma” (large pharmaceutical companies) have not been interested in investing big dollars in an area from which they will not get large returns. Thus, capital investment has been limited.
• Exposing the issue could have impacted the image of sports organizations, and like the tobacco industry, there was always a genuine fear that recognizing this issue would hit profits hard.
• There is a perception that minorities are more highly represented in sports in America, and believe it or not, this is an issue.
• A significant number of people with TBI and concussion belong to a perceived antisocial group, and many of them comprise the prison population and are least likely to succeed in society. They belong to a class of people who are considered to have mental health issues. We all know how little funding is devoted to mental health in America and around the world.
• Persons with TBI, like persons in other mental health groups, are not able to advocate for themselves, and many of them are not in a position to vote or have political influence.
The glory of sports offers individuals the chance for a rags-to-riches story to many athletes and many youths in high school and even elementary school with talent in sports. These youths are often conditioned to use sports as the way out of a bad situation or a situation of disadvantage. Therefore, there is a culture of pushing talented kids through the educational system in a manner that is somewhat a disservice to their future. How many stories have you heard about athletes with promise who never get to fulfill their dream of becoming successful and rich only because they suffered a devastating injury before they had an opportunity to cash in? The economic pressure in low-income communities to ride the wave of opportunity is incredible. For decades, I have been evaluating and treating professional retired athletes, especially ex-NFL players. Many of these ex-players have suffered injuries, the consequence of which they are now living a life of “pure hell.” I have heard those ex-players saying time and again, “I will never allow my kid to play the game.” In fact, their wives and mothers are on the frontline of the issue of kids in sports suffering concussions. I have heard several stories about high school or college athletes wanting to play in the next game right after an injury because the scouts for college or for the NFL are out there and watching every game. When you look at American football and most other sports, including basketball, the appeal of a full ride with all tuition paid to attend some of the most prestigious schools in America is overwhelming. Unitl my daughter went to the University of Michigan, I never understood how strong an incentive sports were to schools in recruiting athletes. In the process of applying to this school, I found that the tuition for an out-of-state student was incredibly expensive as my daughter was not from Michigan. One must ask, what family in America with humble beginnings can afford to pay $250,000 for a college education? Some of the brightest students apply to “Public Ivy” programs and although they are state-funded and may be inexpensive for in-state residents, it could be extremely costly for out-of-state residents. I have great admiration for the school and what they are doing. I can’t even fault them for what they charge, but it is also the politics and the economics of sports and education that drive this phenomenon. While visiting my daughter’s school, we were told something by one of the advisors that stuck with me: Most of the scholarships provided by universities, including the University of Michigan, are for sports and very few for academics. Some schools give out only 5% scholarships, and over 90% of those are for sports. So, if you are a parent out there and you want your kid to get an Ivy League education or even something in the middle, you do not have a prayer of a chance to get into such a school without having your kid in the top 5–10% of the graduating class or being involved as an athlete in a sport that gives them the edge. While I have no way of fully verifying this information, it emphasizes the significance of sports for lower-income individuals.
But hold on, there is another side to this story.
Let us now look at the tale of two well-known Florida towns (Muck City and Liberty City) where American football is the way of life. The first tale is about Liberty City in Miami. In an article published in the Miami Herald on February 20, 2017, and updated on February 22, 2017, by Greg Cote, the caption reads “Liberty City’s youth football isn’t just about scoring touchdowns. It’s about saving lives.” “Coaches at the little league practice are like father figures to the kids,” says Luther (Luke) Campbell. According to the article, Rapper Luke Campbell has been credited with helping kids stay out of trouble and improve their grades in school through his involvement. His institution has become one of the premier youth football programs in the country located in Liberty City (Miami) at Charles Hadley Park, where he helps coach. The article further pointed out that more current NFL players call Miami (Liberty City) home than any other city. In the year before the 2012 season, more than 27 players entered the NFL from 5 square miles of Liberty City. But stories of drive-by shooting, “drug deals gone bad,” and poverty have been part of the Liberty City heritage, sometimes even being compared to living in war-torn Afghanistan (Cote 2017).
The second tale is about Muck City, an area in Palm Beach County, Florida, that includes Belle Glade and Pahokee, named for its dark rich soil. Quoting a story in the New York Times entitled The Way Out by Bryan Mealer in February 2013, this region in the Florida Everglades had become known for migrant workers and minorities who needed employment in the well-developed agricultural sector. The writer described this town as rundown with significant poverty, violence, drug menace and some of the highest rates of HIV infection. The mayor of the city reported rates of unemployment as high as 40%. In the February 2013 Super Bowl, the area’s two high schools located 8 miles apart, namely the Belle Glade and Pahokee high schools, had 5 players that suited up for the game between the Baltimore Ravens and the San Francisco 49ers. These two high schools have produced at least 60 players for the NFL over the years. In this very town (Belle Glade), the Palm Beach County Sheriff’s office estimated that half of the young men between 18 and 25 years had felony convictions. Mr. Mealer’s conclusion in the article was “In Muck City, the well-worn line that ‘football is like religion’ doesn’t even begin to convey its importance. Football is salvation itself, a fleeting window of escape from a place where prison or early death are real and likely outcomes” (Bryan Mealer 2013).
So, there you have it. Can football be the salvation for some people?
I recall taking care of a high school athlete, Eric (case # 6), in the early years of my career at the University of Miami; he was a star athlete. His parents were not poor but could not afford an Ivy League education. Around the end of his junior year in high school, he was by far one of the best quarterbacks in the state, and a number of well-known colleges and universities wanted him. He was from Orlando. While preparing for one of the most important games at the time, he suffered what was believed to be a moderate concussion. Initially, he did not tell anyone but continued with what they call hitting drills in football. By the end of the practice, he had trouble standing and was dizzy, felt nauseated, and had the worse headache of his life. He was taken to a local hospital in Orlando where he was seen and treated with headache medications and given Valium for his dizziness. By day three, he told his parents he was fine and wanted to return to play. His father was delighted and immediately called the coach to say his son was ready to return, however his mother had her doubts.
Around the time that this occurred, the industry was just in the infancy in terms of establishing the guidelines around return to play. Our program (University of Miami Usports) at the time had some pretty stringent restrictions on return to play. If the concussion was a Grade 3 (with LOC or had certain significant symptoms), then the athlete had to be asymptomatic for a minimum of 2 weeks before they could return to play. According to the math, starting from the time he said he was asymptomatic, he was exactly two weeks away from playing in the game where all the scouts would get to see him.
His mother’s sixth sense said that her son was still symptomatic because she recognized that he was not his normal funny and humorous self. He had trouble finding words. He had even lost his temper with his sister and gotten into a physical fight with her, something he had never done before. The father dismissed all of this as the pressure he was under to perform in the upcoming trials.
When the father found out that the mother had contacted us, you can only imagine the screaming and hostile exchange of words between the couple … the father saying that he did not have a chance to make it in football himself due to an injury; wanting to give his son the opportunity to go to a good university, get a solid education, and play football … the mother stating that their son is all they have; if he got hurt, she would not be able to live with herself … I can tell you, some of you reading this book may be going through this issue. This is the real deal of what is going on out there in America and the world with families and contact sports. I was on my way out from the university for an out-of-town trip when I received the call from his mother. The mother, father, and son drove in from Orlando to see me. Understanding the gravity of the situation, I had to reschedule my flight to see them. Listening to the mother’s comment and the concern she was expressing, I paid more attention than I would have usually, and I do pay a lot of attention as is. Eric passed the Sniff Test, and my exam showed that he had a perfect neurological and clinical exam.
When I cleared the patient to return to play, he was already exercising without any reported symptoms. The father and the son by now were giving each other “high fives.” They were both thrilled about the idea of him playing again. The mother went along with the return to play, as I believed that we had followed our guidelines. His game was 2 weeks later, and he had two games back to back. The coaches and athletic trainers noted that on the first return to play game, he was not himself; he was not engaging, seemed distracted, and had little to say. They attributed it to the fact that he had a lot on his mind, given the pressure he was feeling about success. You see, Eric was not asymptomatic. He had the symptoms all along but lied to his family, coaches, athletic trainers, his doctor and to himself. He had dizziness, headaches, and persistent difficulties with focusing and paying attention. His grades began dropping despite his excellent performance prior to the injury. I still wonder what in the world I missed; what caused me not to pick up some of the subtle symptoms and signs in this patient? After that first game, he had a tough night and could not sleep. He had a severe headache and blurred vision. He told no one except his girlfriend, who also told no one. The next game was supposed to be the game of his life; recruiters from the most prestigious colleges would be out there, looking on. “The game of a lifetime” did not turn out to be what everyone was hoping for. He had a pretty bad helmet-to-helmet collision with another player. His instinct made him literally get up and “shake off” the effects of the hit, as he could not fathom disappointing his father, coaches, scouts, and many other stakeholders who impacted his life, including the crowd. He was only able to walk a short distance, and right before the next play was to begin, he collapsed. Eric was taken to a local hospital and found to have a massive hemorrhage with diffuse swelling in the left frontal portion of the brain, causing his brain to shift from the left to the right. He did not wake up for about 2 weeks even after a craniotomy (removal of the skull to remove a blood clot) was performed to decompress the pressure in the brain and remove some of the blood. Eric was my first-ever case of the second-impact syndrome (SIS).
He was subsequently treated at a brain injury rehabilitation center and was able to regain his motor functions, sensory functions, and his cognition enough to be able to finish high school. The real tragedy of the story is that not only was his dream of attending a top university shattered despite his prior good grades, but also the dream of being a star athlete in the NFL. To the mother, the most significant tragedy was when Eric’s girlfriend disclosed that he had symptoms all along, and despite attempts to dissuade him from playing, she could not. Eric had made his girlfriend promise to tell no one. I once spoke to the mother later, and she told me that this experience had changed her life, as she no longer knew if she could live with herself.
What was even more tragic was that after his recovery from this incident, I had to convince the patient and his father that playing contact sports after the injury, especially football, was out of the question, now and in the future. This did not go over well and they sought other opinions that would clear him to return to the sport. When I reviewed the patient’s neuropsychological test results, he had clear deficits in word finding, attention span, concentration, and significant trouble memorizing things. His senior year was depressing, as he needed special accommodations and support to complete high school. He did graduate and was able to get into junior college. Eric completed two years but did not go on to a four-year university to complete his bachelor’s degree. Eric has been a patient of mine for a few years, and his story of shattered dreams has left an indelible print on my mind. So, when I have to clear another athlete after a concussion, I think twice.
