A Player Carted Off and the Game Goes On
On Sunday September 13, 2015, in the first half of a professional football game between Miami and Washington, Dion Sims, a 6’ 4”, 268-lb tight end for the Dolphins, was carted off the field after he attempted to catch an overthrown pass. He made a valiant effort, stretching out in a horizontal leap, but the ball just grazed his fingertips, his impact with the ground just out of bounds near the goal line on the far side of the field. He landed mostly prone, perhaps slightly rotated so his left anterior chest seemed at first to take much of the force of his fall. However, his head was turned to the right, straining his neck toward the playing field and the football he could not grasp. The left side of his helmet – resembling a bowling ball on the end of a stick – was whipped to the ground, causing a burst of debris from the white sideline marker and grass fragments. He did not move at all from a position where his right arm and hand could be seen by his side. The TV camera focused on his prostrate body and the announcer said, “He does not seem to be moving.” There was an immediate surreal replay, in slow motion, revealing the rebound of his helmet off the ground; I pictured what his brain was doing, bouncing around inside his skull. The camera focused in closer: there was still no movement at all, except for the sparse, but very definite arrhythmic twitching of the right hand and fingers. It is unclear if this was a seizure, or a muscle spasm, but it certainly was not Mr. Sims indicating he was alright. Overall, he lay motionless for several minutes, at least. This was a totally helpless young man. I cannot, of course, verify he was even unconscious, but there is no doubt he sustained trauma to his brain. Then, the TV program chose to take a commercial break.
When the broadcast of the game returned Dion Sims was sitting up on the ground surrounded by the trainers for the Dolphins. I noted there was no attempt to protect movements of his neck. Rather sarcastically, I said aloud, “those guys must have x-ray vision if they can tell his cervical spine is OK in a man who has just sustained a significant traumatic brain injury.” Note, there was no response to my statement; I was alone in the room, angry and slightly nauseated at the scene. The announcer did describe a previous gathering of his concerned team mates, which had dispersed as the camera panned to a golf cart-like vehicle being driven to the scene from a different area of the stadium. The announcer stated the game would resume as soon as “Sims is carted off.” He was sitting up in the back of the cart, still without cervical stabilization.
I did not watch the remainder of the game. In fact, I did not watch any more football that day. However, I did try to find out, via ESPN, how Dion Sims was doing; no follow-up on his condition. In broadcasts that Sunday, and on the following Monday and from on-line injury reports and newspapers, there were detailed reports of injuries in all NFL games played that day, but I could find no mention of Dion Sims.
Five days later, the Dolphins report Sims was on the injury list with a “concussion,” along with ankle, hamstring and eye injuries of other players. There is no mention of his “status.” This means it is not yet known if he will play this week. No other details available but no doubt he will be processed in accordance with the NFL “concussion protocol.” This spurious process, not conducted by independent evaluators, does not require the most up to date diagnostic studies with new biomarkers and the most sophisticated imaging studies. Perhaps the NFL and the billion dollar teams do not think it is cost effective. It may be that even the most sophisticated diagnostic procedures will not reveal the extent of Dion Sims’s brain injury. We can say, without question, that if he has had more than one of these injuries, and most likely he has, he is placing his future cerebral function at risk.
Getting Our Priorities Straight About Brain Injury
On the same day Dion Sims sustained his brain injury (please do not call it a minor brain injury or concussion), Luke Kuechly, a linebacker for the Carolina Panthers sustained a “concussion” and in every report it was noted he just signed a 40 million dollar contract extension. It was noted he left the field in the first half of the first game of the season, after signing such a deal. How ungrateful of Mr. Kuechly to not fulfill his contract responsibilities. In another headline, Terrell Suggs, multi-million dollar all-pro defensive lineman for the Baltimore Ravens, sustained a rupture of an Achilles tendon and would be out for the season. This is pointed out not to diminish or minimize Mr. Suggs’ injury, which could put his career at risk, but it surely does not put his future cognitive function at risk.
Please view the stories about Sims, Kuechly and Suggs in light of the recent online report about brain injuries:
“According to PBS Frontline, a new report that was published from the brain bank of Boston University revealed some startling news: 96% of deceased NFL players tested by researchers had evidence of the brain disease chronic traumatic encephalopathy (CTE).” (Visit Concussion Watch on Frontline.)
You must interpret this information with the knowledge that in such a study the patient or family members agreed or volunteered to have their brains examined after death, most likely because they knew or suspected there was serious neurological impairments. But, how many players have not come forward, do not suspect impairment, or have not passed enough time for CTE to do its quiet damage.
And what about college, high school and youth football players? Their brains are even more vulnerable. Additional data from the study indicates of ALL brains examined, not just NFL players, but anyone with a history of playing football at any level, including high school and college, 79% had evidence of chronic traumatic encephalopathy. For the young players, it may take another 30 years before the traumatic degeneration becomes evident. Lest this focus on traumatic brain injury give the impression I am an advocate for eliminating the sport of football, which I am not, I want to provide a personal anecdote that may well have influenced my vocational choices and how I view this problem. For more about this report, visit PBS’s Concussion Watch Project.
When I Played Football: An Anecdote
I played high school tackle football at Santa Monica High School from 1954 to 1958. I joke that it was during the leather helmet days. Actually, in the first year you were not allowed to play with the varsity and were initiated to the “B” football program where the equipment was limited. There were not enough “real” helmets available. So, in practice some of the players did indeed wear the old style leather helmets. The game squads were smaller and if you suited for competition, you got the real stuff: a suspension helmet that was akin to a galvanized bucket strapped to your skull.
In the final stages of my football career the varsity football coach was a man named Leon McLaughlin who was a former center for the Los Angeles Rams in the 1950s. I am fortunate he was the coach when I sustained a head injury early in the fall of 1957. I was playing the position now called tight end; in practice I went up for a high pass and was hit from the front and landed on the back of my head … or so I was told, since I really did not remember what happened. From what team mates later told me, I was unresponsive for at least several minutes, had trouble with vision and following directions, and then very confused. I needed assistance getting home that evening.
Leon McLaughlin was very concerned about my injury and held me out of practice, even when the team doctor, a local GP, said I was fine to play. The examination by the physician, which I remember in detail, while in earnest, was woefully inadequate. Coach McLaughlin, who moved on to coach for several NFL teams, liked to tell stories about his days in football. Most of the tales were humorous anecdotes. But he made an impression on me when he described the players he knew who were impaired after repeated “head injuries.” I am grateful for his caution with the high school players he coached. It is fair to say I am able to put these thoughts together 60 years later is related to Leon McLaughlin’s concern and caution. As long as 50 years ago, the perils of repeated trauma to the head and brain in football were recognized by some experienced observers and still, the NFL persists in diminishing the scientific facts related to traumatic brain injuries.
I contrast Coach McLaughlin’s care and caution with one of his assistants who was also the Athletic Director for the high school. He served as an assistant line coach and his constant command to me was “stick your head in there, Lillard.” I was not enthusiastic about his instructions. I did wonder if this particular coach had played football in the era when they did not use helmets at all.
When Our Kids Play Football: A Cautionary Tale
In the course of my neurosurgical career, I had a particular interest in brain trauma, but it is interesting I very rarely was consulted about brain injuries in football players. There is one situation that illuminates the persistent inertia of our football culture to deal with neurological injuries. In the fall 1983, a 17-year-old high school player was sent to me by a Family Physician whom I knew and respected. The boy was so large he filled up our exam room. He was 6 foot 3 inches and 245 pounds and was well known in the community in West Virginia for his prowess on the football field. However, his coach sent him to his Family Physician because of repeated episodes of electric-like sensations in his arms and the feeling of being unable to raise his arms. At times, the sensation would go down his spine and into his legs. This occurred commonly after he would tackle someone in his linebacker role, or run into someone in his fullback role. He came to me with his mother, and with the message from his father that I clear him to play in the game on the coming Friday night. The boy carried x-rays of his cervical spine that had been ordered by his family physician.
As I saw this frightened young man, his neurological examination was normal and I could not precipitate his symptoms by moving his neck through a full range of motion. He told me did not experience pain but when this thing happened, with this sensation running down through his body, “it scares the shit out of me.” He listened intently as I explained the findings on his x-rays. The anterior-posterior diameter of his cervical spinal canal was 8.5 millimeters. That means the bony canal or tunnel of his spine was so narrow his spinal cord was in constant danger of being compressed or choked with motions of his neck. The standard normal lower limit of this diameter in an adult is at least 11 millimeters. This is a very tight space. After a long conversation about what these findings meant for his football career, both he and his mother were subdued but not anguished. I provided a note to give his coach indicating I could not clear him to play football.
Two days later, the boy’s father came to my office unannounced and waited until I had the time to speak with him. The father told me I had ruined his son’s life. He indicated his son was going to get a full ride to Penn State and his son had the skill to be a professional football player. After explaining the findings and the dangers, the father stated he was going to get a lawyer to force me to change the recommendation, since the coach would not play him without clearance. The father left my office after filling the air with expletives about my credentials and familial ancestry.
The next day I received a call from a lawyer who was less contentious and asked if there was any way to settle this matter. I told the lawyer I could not change my recommendation, but I could suggest getting another opinion. I said I would try to facilitate a consultation by the neurosurgeon considered the authority in the United States on neuro trauma. That physician, Joseph Maroon, was located at the University of Pittsburgh Medical Center. I would not contend the decision if Dr. Maroon made the decision to clear the boy to play football. Two weeks later, I received a copy of the evaluation done in Pittsburgh confirming the diagnosis and the recommendation that football was not in the future for this boy. I learned from the referring Family Physician that the father remained very angry at me. Before I left the practice in West Virginia, I learned the young man had decompressive surgery on his cervical spinal canal stenosis.
I did not get further consultations for football players with head or spine injuries. That does not mean there were no injuries.
Thus we cannot blame the NFL entirely for this ongoing endemic of neurological injuries, both traumatic brain injuries and spine/spinal cord injuries. Parents, coaches, school administrators all contribute to this problem. It is a cultural issue. Alongside the traumatic brain injuries in our military population, we are creating a predictable and massive chronic health problem that will haunt us in the future.
But the answer is not in threatening to eliminate football, soccer, or any other sport that poses life threatening risks. The answer is being reasonable and responsible: first, prevention of injury; second, early detection — not “putting your head in there” — with sensing devices that are already available; and then, prevention of repeated injury. Maybe, if the civilian culture can be the leader, we can get the United States Military to take an enlightened view of neurological trauma. Remember, the force of the blast on the brain from an explosive device is exponentially greater than the injury Dion Sims experienced.