Showing posts with label traumatic brain injury. Show all posts
Showing posts with label traumatic brain injury. Show all posts

Sunday, June 27, 2021

The Spiritual Journey From High School Football



About 2 years ago my wife said to me one morning “who is this guy who keeps texting me?” I looked at her phone and recognized the name immediately. He was the quarterback from my high school football team. More correctly it was the high school football team I was on when I was a sophomore in high school. I had the immediate association to his physical appearance and considerable athletic ability. To this day he probably was the most gifted high school athlete I had ever seen. He didn’t look like a high school player - more like a college player. He was also an excellent basketball player and sprinter on the track team. He was the fastest man over 100 yards in high school. Why was he suddenly texting my wife?

He was going to be inducted into the local athletic Hall of Fame. He was trying to organize a reunion of our 1966 undefeated high school football team. His plan was to get as many of us back there as possible - details to follow. There were 2 or 3 subsequent postponements of the reunion due to the pandemic. But yesterday on 6/26/2021 it finally happened. Twelve of the 22 players reunited for about 3 hours at a local bar. As far as I know three of my teammates are deceased and the remaining players could not be located or decided not come. The head coach was also in attendance. The assistant coach is deceased.  All of the attendees got baseball caps with their name and numbers embroidered on the back. The front of each cap simply said “Undefeated 1966 AHS Football”.

Unlike my high school reunion, I had the opportunity to say something to all my teammates. I remembered who they all were and details from our past. I know that many had significant problems in life including life-threatening health problems. I learned about their relatives who had similar problems. But most of all I learned about what that football season meant to the people who made it back to the meeting. I know that memories from over 50 years ago can get complicated and distorted. As we all sat around a table there was a collection of newspaper articles and photographs from 1966 to provide partial corroboration. There were some intense memories from the past that haunted some of the players. There was also active feedback from the coach about a few incidents where he realized that the plays he was calling were being ignored. My intention in writing this post is not to identify people with problems or criticize people, but to look at an event with obvious meaning as well as the meaning that may have been missed at the time.

Our quarterback started out with some self-disclosure of mistakes he had made during the championship season. Other players who were involved with those mistakes corroborated them immediately. Our center for example recalled a fumble on the opponents 1 yard line and the fact that it occurred on a silent count. For 5 decades our quarterback was thinking the fumble was his mistake, but our center let him know that he forgot the count. There were several other incidents involving typical football mistakes that people had been thinking about since 1966.  Resilience came up as an outcome of the coaches role in helping us overcome adversity.  

A significant injury was discussed. From the description it sounded like a traumatic brain injury, but back in those days any head injury with partial or significant loss of consciousness was referred to as a concussion. There was no grading system but persistent confusion or memory loss might eliminate a player from the game although that was certainly not guaranteed. More than one concussion led to a medical evaluation but again there was limited medical expertise in traumatic brain injuries. It led me to recall a lot of headaches from playing football. We would practice twice a day in hot weather hitting a blocking sled and doing full contact drills. There were days where the headaches just did not clear up.  I was also reminded of the only significant traumatic brain injury that I sustained when I ran into one of my teammates playing in a touch football league. In fact, I approached him at this reunion and joked that the last time he and I met - I was out of it for the next 24 hours. I had to explain that we were both defensive backs running full speed and I ran into a shoulder after diving for the ball. He did not recall the incident.

There was a strong underdog theme. At one point in the year, we did not have enough players to scrimmage so the coaches had to play defensive half backs. Many of the teams we played against had much larger players and significant depth.  That led me to recall our coaches quote to the press: “We are not big - but we’re slow”.  Our coach recalled that in some of the venues we were ridiculed for looking raggedy and not having many players. We were accused of running up the score against some teams to improve our overall ranking.  The coach found this humorous because there was no second team to put in.  At one point during the discussion, one of our receivers took over and talked about how he and one of his friends in the offensive and defensive line got psyched up for the game. He gave an inspiring and expletive filled speech about his love of football, how he liked physical contact, how he liked playing offense and defense. He presented it with such vigor that it seemed like he was ready to play - right then.

For some reason, I had forgotten how tough these guys were. We were almost all working class.  Half of us were from the East End and half from the West End of town. Some played with significant physical disabilities. It was the height of the Vietnam War and many would go into the Marines and the Army after graduation. Many would go on to play college football. I would just catch glimpses of their lives from time to time.  Everyone had a unique trajectory from that winning football season to where they were on June 26.  At one point a small group asked me what my trajectory was and I told them a variation of a story I have been telling for the past 10 years:

The only reason I ended up going to college was to play football, be a football coach, and teach physical education.  I had a football scholarship to a small college in the area, but within a few weeks, I developed a gangrenous appendix and was hospitalized for a week.  The coach came in and told me that the scholarship was mine even though I could not play anymore (I had a healing surgical scar in my side that was still healing after a drain was removed). I probably was headed to be a version of a hippy anyway. Another professor visited me and told me to forget about Phy Ed and football and concentrate on something else.  I had excellent chemistry and biology professors and knew that I wanted to be like them and know what they knew.  From there it was a change to biology and chemistry, the Peace Corps, a plant tissue culture lab and medical school.”

That’s the short version.  There are embellishments for comedic relief and more details if anybody wanted to hear it.  I leave out the heavy parts about being depressed to the point my grandfather showed up one day to encourage me to stay in college and not knowing what was wrong with me until I developed severe abdominal pain. I leave out the part about not taking a student deferment during the lottery for the draft.  A high lottery number rather than a conscious decision kept me from being drafted.  All part of the lack of a coherent plan. Nobody wants to hear about all of that. I never played college football.  The point is – I would never have stepped into that sequence of events culminating in medical school and psychiatric residency without that football scholarship. I never would have had that football scholarship without playing with this team and being coached by this coach. Some people will tell me that sequence of events would have happened anyway. That I would have made it happen through another channel. Whenever I mention being lucky on this trajectory, I encounter aphorisms like “Luck is just preparation meeting opportunity” and others.  But I really was not prepared to do anything at that point.

The only thing I was prepared to do in high school was play football. The teaching and guidance side was totally lacking. I can not recall a single piece of good advice that I received from a teacher or guidance counselor in those years. And the teaching was atrocious. You showed up, put in the time, did not create any problems and graduated from high school. The blue-collar ethos of education.  You did not have a plan until you got to the next stage. The modern-day stories of high pressure on high school kids to get into an Ivy League schools and parents going to extraordinary and in some cases illegal lengths to get them in - is lost on me. I am the poster child for getting into whatever college wants you and establishing goals after getting there.

Football was the initial pathway.  At the Reunion, the coach discussed some of his initiatives including the first strength training program at the school along with associated competitions. I remember summer training sessions including agility drills.  I excelled in agility drills and back and forth sprinting drills. In my senior year, I could equal or beat the fastest running back in the agility drill even though he would beat me by a mile in 100 meters. These summer sessions were something we all looked forward to and it was the only planned activity in my life for the 3 years of high school.  The Coach gave us a glimpse of what it took for him to implement these plans and all of the resistance he met along the way.  That resistance came in the form of administrators claiming that he was running afoul of certain regulations, personality conflicts, and suggesting that he should work the pre-season for free even though he was already undercompensated for the amount of work he was doing. Providing me with some structure to start to get my life together came at a considerable cost to the only guy who was doing it.

Several of my teammates provided additional stories about the immediate benefits of coaching. How to play against a much larger man with limited lateral movement.  How to make adjustments during the game, based on observations by coaches who were at ground level on the side lines, attending to the injured on the sidelines, and changing overall game logistics. High school coaching is a multi-tasking job and school districts get their money's worth from coaches.

One of the most important aspects of my life trajectory has been identifying with teachers along the way.  Most of that emphasis was in college at the conscious level. But did it occur in high school football?  I was never encouraged to play any sports by my father. I learned after his death that he was quite accomplished in baseball and softball in his early twenties. By the time I knew him well, he had been working a thankless job for twenty years. The only sports advice he ever gave me was: "Look - if you want to play sports be clear that you are playing it for you and not for me." He did live to see this football team and attended the end of season banquet prior to his death in 1967.  I never got the chance to completely understand his sports advice, but speculate that it was from having to fish every day during The Depression to supply food for his family of origin - whether he wanted to or not.  

Both of our coaches were young men, accomplished athletes, and had unique personas. I remember the head coach bench pressing a significant amount of weight even though he was a quarterback in college. For the rest of my family, sports were something you did into your early 20s and then you settled into a fairly sedentary lifestyle. Out of college and then again out of med school I embarked on a lifelong schedule of rigorous training for no reason other than being able to do it.  That continues to this day. Would I have logged all of this activity if I had not played high school football with this coach? Probably not. Was there a degree of unconscious identification with this coach?  Probably.

The developmental aspects of high school football are undeniable and the stage we were all at during the reunion was undeniably different from high school. High school male athletes are competitive either by choice or necessity. It was probably the most significant motivator. I can remember thinking about the difference between competing with myself and competing with others as I was running a long sprinting drill in the 90 degree heat that occasionally happens in northern Wisconsin. In that drill 5-10 players spread out across the field and run out to the 5 yard line and back and then the 10 yard line and back until they have reached the 50-yard line and back.  At some point during that drill you realize that competition is irrelevant because it really comes down to survival and in that sense you are competing against your own physical limitations.  That familiar mind set was with me for the next several decades of cycling and speed skating. With a single exception - I preferred to do both activities alone – just me and the rhythmic breathing and sweating of that familiar sprinting drill.

The competitive aspects of high school sports also play out in other ways. Clique formation, hazing, bullying, sarcastic comments, and various forms of acting out that are expected of teenagers who we now know don’t have fully developed brains for another 10 years. That was moderated to some extent by the shared suffering of football.  At the Reunion it was fairly clear that there were many accomplishments over the course of these lifetimes but also much suffering. We were all grateful to have survived so far and saddened by the loss of our teammates who did not.

55 years had passed and, in some ways, we were a better team.

 

George Dawson, MD, DFAPA


Postscript: 

If I am correct in my analysis (or not) - I am grateful to have had this experience in high school.  I am grateful for my teammates many of whom I consider to be friends but also the Coach and Assistant Coach who clearly did not get enough credit for what they did. I made the common mistake of also taking that coaching for granted until I realized that my entire career may have been based on it.


The commemorative cap:




Supplemental Qualifier:

I don't want to give anyone the impression that this is an endorsement for football or other contact sports.  Football is a collision sport and there is an expected morbidity associated with collisions. Chronic traumatic encephalopathy is one outcome that has received a lot of press. My speculation is that spinal problems also occur as the result of spinal compression and hyperextension movements that are harder to detect due to the high prevalence of spinal problems in the general population that does not play contact sports.  One of my teammates sustained a cervical spine fracture from football but it did not result in paralysis.  As a psychiatrist, I have seen a significant number of people with traumatic brain injuries and severe musculoskeletal injuries from collision sports.  The number of women with those injuries has increased as their exposure to these sports (soccer, lacrosse, ice hockey) has increased.  I have seen young men and woman in their early 20s with significant disabilities from these injuries. In some cases they have also had severe post-traumatic stress disorder (PTSD) from either the injury or the subsequent course of treatment. 


 


Wednesday, August 7, 2019

Dr. D Gets a Traumatic Brain Injury (TBI)







One of the best illustrations of a psychiatric concept is your own personal observation as a physician.  This really happened to me quite a while ago but even that has implications....

When I was 22 years old I was playing in a football game. It was a city league touch football game. At that point I had probably been playing football in one form or another every day of the year for the previous 10 years.  The typical game was passing 2 on 2 in the street.  In this game, it was across the whole field and I think we had 8 men on the field.  I knew everyone on the team.  On defense, I was a cornerback and on offense -  the quarterback.  In the context of all being 20+ year old men we were all fairly intense.  That probably explains why when a pass was thrown into our defense I ran and dove headlong for the ball.

That was just about the last thing I remember from that day. I can recall glimpses of the fact that I apparently stayed in the game. No recollection of getting my hands on the ball, the impact, breaking my nose, bleeding somewhat, how long I was on the ground, or other plays.  During the dive for the ball, I smashed my face into the shoulder of our other cornerback and was knocked out.  Later he told me his shoulder was sore from the impact. We were both running toward one another at full speed.  A few flashes of standing in the huddle and not responding to questions very well is all that I can recall for the rest of that game.  I made it home.  I vaguely remember an argument where I was asked why I was so irritated. My memory and baseline conscious state didn't come back until until about 2PM the next afternoon in a physical chemistry class.  That was about 18 hours after the game.  At no point was I seen by a physician.

The first question that comes to mind is "Was this a concussion or a traumatic brain injury or both?"  I ask every person I see about head injuries and try to figure out if there was an associated brain injury.  It is one of the most important parts of the psychiatric assessment.  I get a full spectrum of responses from people who say they were knocked out but did not have a concussion to people who had a concussion but were not knocked out to those were in a coma for 5 days or more.

For people of my generation there were two myths that actively interfered with the care of traumatic brain injuries and concussions.  The first was that you could just return to the game.  The number of people I have interviewed who were football or hockey players who tell me they were knocked out multiple times including several times in the same game is shocking.  Returning to the game with a concussion injury or mild TBI is a horrifically bad idea because if another incident occurs it could lead to a devastating brain injury that could be life-threatening.  The second myth is that some players cannot be easily replaced in high school or college. If your star player gets a concussion, the chances that the replacement will not do as good is the difference between winning and losing. The problem with that logic is that the performance of the impaired player has to be seriously deteriorated. On my team, I was certainly not the star but we had no replacements.  That is not the best plan.  To this day, I do not recall the second half of the game but it was not good.  The risk of a life threatening injury is certainly not worth the potential reward of hoping to maintain expected performance to win a game.

What are the current definitions of traumatic brain injury and coma?  I had the opportunity to attend a recent Door County Summer Institute program given by Sheldon Benjamin, MD.  The program was entitled Practical Neuropsychiatry for Clinicians. The second day of the course was all about traumatic brain injuries that included the definitions, clinical syndromes, diagnosis, pathophysiology, and treatment.  Traumatic brain injuries are very common in the US in terms of overall incidence and prevalence (2) and also by comparisons with other neurological and psychiatric diseases.  56,800 people died of TBIs  in 2014 including 2.529 children.  The common injuries leading to death include intentional self-harm (32.5%), falls (28.1%), and motor vehicle accidents (18.7%).   Older patients are at highest risk.  The overall prevalence as a percentage of the population at about 1.5% rivals major mental disorders.

The goal of this post is to describe my traumatic brain injury from long ago using modern criteria to suggest the best possible format to record this information.  First off, was it a concussion or a traumatic brain injury (TBI)?  The CDC definition of TBI is a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or a penetrating head injury.  The jolt to the head can include blast injuries or any sudden acceleration/deceleration movement to the head.  Disrupted brain function must occur in proximity to the injury and can be observed by changes in level of consciousness, memory loss, focal neurological findings, or additional mental status changes.  Once the mechanism of injury and clinical features have been determined further classification into mild, moderate and severe TBI can be made.

And what is the difference between a TBI and a concussion?  Concussions are by definition with or without loss of consciousness but are described with a number of symptom complexes (headaches, irritability, insomnia, depression, etc) but there are no major neurological symptoms or imaging evidence of injury.  The classification of mild, moderate and severe TBI is done on the basis of the time where consciousness was lost, Glasgow Coma Scale ratings at the time of presentation (see Supplement 1), presence of neurological findings, presence of imaging and EEG abnormalities.  Using these definitions a concussion would be considered a mild TBI according to those categories.



My opening question to people is whether or not they have ever been knocked out. An affirmative response means a concussion or at the minimum mild TBI.  If no LOC questions about associated post-concussion symptoms are relevant.  On a clinical basis, using this scale retrospectively without access to the original record can be a problem, but patients often remember relevant parts of the records.  For example, people often recall if they were told that their imaging study was abnormal or not. They can recall hearing that they had "blood in the brain" and in some cases that they were in a TBI rehab program for a while.  A description of the approximate periods of retrograde and anterograde amnesia is also useful.  For example, in the case of the TBI that I sustained - it would be mild.  I could also say I had a concussion. Both are better specified with comments about the specific features.  Actual loss of consciousness (LOC) was on the order of minutes.  Altered consciousness was about 18 hours.  My guess is that the GCS would have been a 15 if I had been taken to the emergency department and because I was not seen by a physician no imaging studies or EEGs were done.  Subsequent to this injury I have had normal MRI scans and EEGs.  If I was seeing myself as a patient based on that history I might document:

"There is a remote history of a mild TBI that occurred following a collision during a football game with several minutes of LOC, a minute or two of retrograde amnesia, and 18 hours of altered consciousness with patchy anterograde amnesia. There were no postconcussional symptoms past 18 hours. The patient has had subsequent MRI scans of the brain and EEGs  both years later that were noted to be normal."

Other useful descriptions include what the ICD-10 describes as the disparate symptoms of postconcussional syndrome.

In the weeks ahead I hope to post more information on the pathophysiology of traumatic brain injuries and why that is important to psychiatrists.  For now I will just be grateful that the poor judgment of my 22 year old self did not lead to significant disability or death.  There is some epidemiological data to suggest patients with TBIs are more likely to get Alzheimer's disease so I may not be out of the woods yet.  The good news is that this is an active area of research, that treatment approaches do work for people with deficits, but like all of medicine these days they are rationed by health care companies.


George Dawson, MD, DFAPA


References:

1:   Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA. Link

2: GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 Jan;18(1):56-87. doi: 10.1016/S1474-4422(18)30415-0. Epub 2018 Nov 26. PubMed PMID: 30497965. Link

3:  Brain Injury Awareness Month — March 2019. MMWR Morb Mortal Wkly Rep 2019;68:237. DOI: http://dx.doi.org/10.15585/mmwr.mm6810a1

4:  Bellner J, Jensen S-M, Lexell J, Romner B. Diagnostic criteria and the use of ICD-10 codes to define and classify minor head injury. Journal of Neurology, Neurosurgery and Psychiatry 2003;74:351-2. Link

5: Defense and Veterans Brain Injury Center.  ICD-10 Coding Guidance for Traumatic Brain Injury. Link


Additional Resource:

Neuropsychiatry Pocket Reference or Brain Card by Sheldon Benjamin, MD and Margo Lauterbach, MD is a booklet of 7 laminated reference cards that covers the neuropsychiatric exam and syndromes of interest to psychiatrists working in this field. It is an excellent inexpensive resource that connects the purchaser to a web site of extensive additional information. Available from braineducators.com





Supplementary 1: