February 15, 2016 - Dr. David Chao
Monday Morning MD: Medicine has to catch up
We have to do better. Despite a decade of head injury in the headlines, there is still much more we don’t know about concussions than what we do know. We are a long way from prevention. There is still no proven treatment. The diagnosis and return to play is very subjective. There is not even a definitive method to determine CTE (chronic traumatic encephalopathy) except for examining the brain after death. As an example of how little we know, concussions are still all lumped together as one diagnosis. It’s like the 1960’s for knees when every injury was a sprain. There were no MRIs, very little treatment and arthroscopy didn’t exist. Doctors didn’t understand the importance or function of the ACL and a tear ended your career. Surgeons routinely removed meniscus with open incisions thinking it served no function and inadvertently created arthritis. Surely all concussions are not the same, just like all knee injuries are not the same. One day soon I hope we can categorize different types of concussions. Perhaps a temporal lobe grade 2 concussion will be treated with a different protocol than an occipital lobe grade 3 injury. I pen this column on the flight home from attending the “celebration of life” of yet another professional athlete that has taken his own life. I have the misfortune (and fortune) of knowing three friends, all who once were at the top of their sport and now are no longer with us. Although the average sports fan would recognize their names, their identities are not important to this narrative. The fact that they all died young in their 40’s and left behind families is tragic. This is not a political piece. I am not hyping the dangers of CTE nor downplaying concussions as part of the game. I am not anti NFL in its handling of head injuries nor pro NFL. Not all of my three athlete friends who committed suicide were even football players. One friend was tested and definitively found to have CTE by multiple centers. One was not tested to my knowledge. It is too early to know if my most recent friend to pass away had CTE. Head trauma is a widespread problem and not limited to football. Boxing, hockey, soccer and action sports are just a few of the other disciplines that have been implicated. This is not just a sports problem as the military has a significant concussion issue as well. The NFL has a chance to become a societal leader here: not just for football at college, high school and youth levels, but for all sports and the military. Although they did not play the same sport, I do know my three friends had something in common. Among the different friendship circles, each would be consider charismatic, happy, carefree, easy going and loved by all. Hardly the profile I thought would put someone at risk to commit suicide. These athletes were not outliers with drug and alcohol problems. All three were upstanding citizens who were pillars of their communities. The scary thing is that I have since found out that these three aren’t the only ones to have considered suicide. I know of several others who have been depressed enough to consider it. I was surprised to have another professional athlete friend confide in me after Saturday’s ceremony that he too has considered suicide. Even a recently retired Pro Bowl player who I thought had the best perspective on life, a great wife and two young boys had his retirement struggles. http://www.theplayerstribune.com/nfl-retirement-nick-hardwick-chargers/ If it can happen to him and these three, it can happen to all of us. How many others are out there that have not come forward for help? Psychologists suggest impulse control is what prevents many of us from taking that fatal step in a time of darkness. Perhaps what made these athletes great was their commitment and “go for it” attitude. Possibly that is what contributes to their no longer being here. In medicine, we demand proof before we come to an absolute conclusion. That makes scientific sense; however, when lives are at stake and there is mounting evidence, we need to act quickly. When a fire starts to burn the immediate goal is to extinguish the flames and worry about how it started later. Let’s focus on the problem at hand and not just who is responsible for the cause. When there is a potential cure for a deadly cancer, we don’t wait for conclusive proof before implementing treatment. We should take effort to care for those suffering from the effects of head injury while scientists determine the cause of CTE. Even if we prevent every concussion and potential CTE case going forward, we have a generation of at risk athletes and military personnel to deal with. CTE has become the buzz letters but even if no CTE, it doesn’t mean no long-term symptoms from concussions. Recently NHL enforcer Todd Ewen died of a self-inflicted gunshot wound and was found not to have CTE, yet by report had memory loss and depression. http://www.nytimes.com/2016/02/11/sports/hockey/autopsy-shows-the-nhls-todd-ewen-did-not-have-cte.html?_r=0 On the other hand, the presence of Tau proteins (how CTE is diagnosed) does not mean someone will have symptoms. Researchers should all work together and share data. It’s not about who gets credit. The disease process of CTE was discovered in the 1920’s, not in the last decade. Let’s stop fighting over the brains of the deceased and collaborate. Stop pointing the finger at fault and find a solution. That is how science is advanced. As an orthopedic surgeon, I don’t have the knowledge of the human brain to find a cure for concussions. As a team physician and sports medicine doctor, all I can do is promote awareness and provide resources for former athletes. As a part-time media member, I hope to change the concussion landscape to one that looks for solutions rather than finding blame. As a friend to former players, all I can do is encourage them to talk to each other. They will be surprised how many others share their experience. As a professional athlete or an everyday guy, please reach out to your friends and colleagues. Guys keep their feelings inside. If you talk to your buddies, chances are some with have gone through or are going through the same things. I don’t know if concussions were all, part or none of the reason my three professional athlete friends are no longer with us. I am not sure it makes a difference. All that matters is we need to focus on how to prevent a fourth.