by Ken Dryden
“Do you think I’m jumping up and down with happiness?” he says when he talks about the possibilities missed. “I’ve been working on the brain for over thirty years. I’m very frustrated. I know I have some answers, yet I cannot implement them. But you know, I try to control my emotions because if you don’t, you get even worse results. So when I’m asked to give interviews, I never refuse. I go to conferences. I present these results. I try to communicate everything that I know to anybody that invites me to speak. That’s what I do.”
When not much changes, first he thinks it’s their fault—those in authority who have in their hands the power to change things—then, like Johnston, he thinks it’s his, because he hasn’t delivered his message the right way. He tries to imagine how they, how all of his audiences, think. “The league has a business interest,” he says, “so maybe if I talk about things in a business way, that if they do these scans before and after, if they prolong an individual’s career then it may be in their own best interest in the long term; that there’s a financial dividend.” But mostly, Ptito believes, the answer for his patients, for anyone with brain injuries, lies in knowing more, so that others can know more and make smarter decisions. It has to be this way. Knowing more is what he does. Making smarter decisions is what Bettman, Echemendia, and Molson do. They are all linked.
Ptito talks excitedly about new technologies that will allow scientists to know more. “I just got a grant to buy a new MRI,” he says. “The one we have now doesn’t let us see any change in the brain’s structure, and we know that there must be changes, particularly in connectivity. It may not be that one single area of the brain is affected by an injury—it’s not that you’re going to see a blob of blood or anything. It may be that the connections between two regions are interrupted.” He and his colleagues will have the new MRI in 2018. They also have almost enough money now to run a positron emission tomography (PET) study on retired players. A radioactive substance that binds to certain proteins will be injected into the players, and a subsequent PET scan might reveal the presence of CTE. This, while a person is still alive.
“Imagine,” Ptito says animatedly, “then we can start working on medications. We can repeat the tests and see if there is improvement. We can prepare the families, and explain to them what may be happening because we’ve seen this and that. We can prepare the player. We can give him psychological support. Imagine somebody like Steve Montador, if you’re thirty-five years old and you receive a diagnosis of CTE. What do you do? There’s a whole life ahead.
“You have to help these people. Are they going to remain depressed for the rest of their lives without anybody doing anything? It’s not everybody that is able to commit suicide. We would know the CTE is there. Perhaps we can improve their quality of life and slow down the process.” To a scientist, this represents hope; to a thirty-five-year-old hockey player, it does not. Ptito doesn’t need these new machines to know that his patients have a problem. He sees it in their behaviour. They have memory loss that is a whole lot worse than simply forgetting where they put their phone or their car keys. They make crazy, erratic decisions that are a whole lot worse than just having a bad day. They are anxious and depressed, and some things set them off when they never did before, and other things don’t when they did and should. There is something wrong with them; he can see that. It doesn’t matter what his fMRI or PET scan shows or doesn’t show.
But he needs these machines to also find out lots of other important information: to see if CTE is like other diseases that are better known and better studied—Alzheimer’s, Parkinson’s, ALS—so that through these other diseases he can learn, postulate, go off in promising and exciting directions.
Ptito also needs these machines so that other people, the decision-makers and those with influence who aren’t scientists, can see the damage for themselves, and understand the problem. When they see a broken bone on an X-ray, they know. When they see a tumour on an MRI, they know. But at the moment they can’t see CTE on any screen. “Where is it?” they say. “Show me. If I can’t see it, how do I know it’s there? How do I know if anything is even wrong? He looks fine.”
Henry VIII, in the early years of his reign, was considered even-tempered and wise. After two jousting accidents, one that left him unconscious for two hours, he was erratic and rage-filled. A Yale University neurologist thinks there may be a connection between the incident and the change in his behaviour. But Henry looked fine—and kings can do anything and be forgiven (except, perhaps, by the Catholic Church).
In recent years, the concussion debate has become all about CTE. And before death, CTE isn’t there because we can’t see it. After death, it’s too late. With the focus on CTE but with no smoking gun, all the signs seem not so important. They aren’t dramatic enough. But to Ptito and others, something is wrong, because depression is there, because crazy, stupid decisions are there, because memory loss is there—and these aren’t there in a normal, healthy thirty-five-year-old male. Brain injuries are not invisible. This person, that person may look fine, but hang around them a bit. Watch them as they live out their day. Do they still look fine?
Ptito is a clinical neuropsychologist; so is Echemendia. Neuropsychologists study people and behaviour. They can’t see everything that has gone wrong in the brain, but they don’t need to. They see a problem with their own eyes, and in the results of the tests they administer. They don’t see it in the concrete brain; they see it in the concrete person. To others, who don’t wish to see unless they want to, that isn’t enough.
We all want to know things for certain. And we especially want to know if the consequence of our knowing would mean the need to change what we already do. Change is a nuisance. It takes time, costs money, and creates uncertainty. We already know how to do what we are doing, but we might not be able to learn something new. We know the good of what we already have, and we know how to live with the bad. And we only think we know the good of the new; and we certainly don’t know the full potential of its bad, or know if we can deal with that. So if depression, erratic behaviour, memory loss, or worse have to exist, we don’t want them to be because of thunderous hits or uncounted blows to the head. We want them to be about things that we can’t do much about, like genetics; or things that we think we have some control over, like alcohol or drug use. So we do what we want to do, and make its case, not what needs to be done.
Many players and non-players who have suffered head injuries have substance abuse problems. They have pain, and they medicate their pain through doctors—legally or illegally, correctly or incorrectly—or they medicate it themselves. After a while, pain is pain. You get rid of it any way you can. When a player who has had head injuries and also a history of alcohol and drug abuse shows symptoms of brain damage, what’s the story? Is it about hits, or addiction? It seems so confusing, so complicated, so unclear. It’s the chicken and the egg.
It seems easier, even more responsible, not to think about having answers at all. There is so much we don’t know, and shouldn’t pretend to know. Shouldn’t we just wait? But our perceptions of what is wrong and why don’t wait, with unfair and destructive consequences. Because one thing we can see; one thing we can’t. We can see the unhealthy symptoms—the drinking and drugging. We can’t see inside the brain. So the story, about hits and addiction, comes to be about addiction first, because it is easier to understand and see. (And hits get relegated to a parenthesis.)
And the story of the brain-injured player can be so sympathetically told. It’s about this really good guy who loved to play, who loved his teammates, and loved the game. Who played the game the way it is supposed to be played—with dedication and respect. He stood up for his teammates no matter the circumstances. He stood up to his opponents no matter how big and tough they were. He worked hard on the ice and off. Injured or sick, he played because his team needed him, and his teammates counted on him because they knew that they could.
But he was young, and things happen when you are yo
ung. Young people are healthy and strong, and think they are invincible. They want to do everything; Steve wanted to do everything. He had money. He pushed the limits, because he was curious and young; because he was a player. Youth, money, opportunity—it can be a dangerous mix. And Steve was getting older. He could see the end of the line. He had played hockey all of his life: it’s what he did, it’s what he was about, it’s where he found his purpose, his meaning, his pleasures and joys. Now his hockey life was about to be over. Now he had fifty years of his life in front of him. What was he going to do? Where would he find his new purpose, his new meaning, his new joys? He was feeling the pains of injury and age. Of course he was. He was depressed. Who wouldn’t be? He was lost.
It is all so understandable and sad. For everybody involved, the brain injury narrative can be what you want it to be. For players and former players, it can be about alcohol, drugs, and “transition,” because if it were about CTE that would haunt them every day of their life; and alcohol, drugs, and transition, in theory at least, they can control. For the league, it can be about something rare and tragic. It can be a one-off: the unknowable life of one person. In this way it doesn’t have to be about changes in the game, about its more frequent, more forceful hits; about decisions made, or not made. In this story, there are no villains. Only the ineluctable circumstances of life. And a really great guy.
Thank you for your service.
—
Just when Dr. Ptito thinks that things are getting a little better, something happens that makes him wonder. He remembers a game in December 2015 between Montreal and Columbus. Canadiens forward Tomáš Fleischmann was skating up the boards with the puck, and Nick Foligno of the Blue Jackets stuck out his knee to stop him. Nathan Beaulieu of the Canadiens confronted Foligno, and the two of them squared off to fight. Both are strong, tough guys, and things were fairly even until Foligno hit Beaulieu with a right hand to the head, and Beaulieu crumpled to the ice. He was then directed to a “distraction-free environment,”—a “quiet room”—as required by the NHL’s regulations, in the Canadiens’ dressing room area, where he went through the league’s mandatory concussion testing and protocol administered by the Canadiens’ team doctor.
Seven months earlier, during the playoffs, Beaulieu had been blasted with a shoulder to the head by the Senators’ Erik Karlsson, a hit that was run and rerun on highlight packages all over Canada and the U.S. Ptito was at that game. He also watched the Columbus game on TV. “Beaulieu got up and he was kind of wobbly [after the Foligno punch],” Ptito says, “and to me it was a concussion for sure. Then a few minutes later, he returned to play.”
Ptito was incredulous. It seemed to him an easy case: Beaulieu was in a fight, everybody was watching, nobody was distracted from it by anything else; everybody saw the punch, everybody saw him go down, everybody saw him wobbly; they’ve all read the stuff about head injuries and concussions. It was the twenty-sixth game of the season, not a playoff game; there were fifty-six more to play.
So, Ptito knew, Beaulieu was not coming back to play—and then he came back to play! How could that be? Then Ptito answers his own question: “They tested him in the locker room and he passed.” Period. But he knows, and the Canadiens’ doctors know, that players find ways of passing these tests because they want to pass these tests. Beaulieu is a big young guy. Known mostly for his play with the puck, he has carved out a role with a reputation for standing up for his teammates—one that matters to him and to the team. That’s why he took on Foligno. Yet not many months earlier, he’d been crushed by Karlsson and didn’t play for seven games. That can’t happen to team guys. Team guys have to stay in the lineup. They have to be there to stand up at stand-up times, and they can’t do that taking a test in the dressing room. The doctors knew that. They have their tests, but they have their eyes too, and they knew Beaulieu’s history. That’s what mystifies Ptito. Why didn’t they say, “I don’t care what the tests say. You’re done for the night, Nathan.”
It is the power of wanting to play. A player absolutely wants to play. One, because he wants to play. Two, because he thinks his team needs him. Three, because his teammates expect it of him. Four, because his coach expects it of him. Five, because the fans hope it of him. Six, because every player is replaceable, and if he doesn’t play, like Wally Pipp he may never play again. Seven, because the commentators will say, “He’s a hockey player. He’ll be back.” Eight, because he is young and thinks he can, and he thinks there are no consequences if he does. Nine, because if he doesn’t play because of a head injury, he will become a more vulnerable, less desirable commodity. Ten, because if he does come back to play in the same game, his injury can’t be a concussion, because if it were a concussion he wouldn’t be allowed to play in that game (even if it is one).
It is not just about adults—players—being old enough to make decisions for themselves. It is about these adults having people around them who are more than just notionally sensitive, notionally listening, notionally good guys, notionally with a reputation for being among the best in the league; people who will stand up to the player’s drives and needs that they helped to instill and create and encourage; people who will safeguard a player from himself. Tests can reveal; and tests can also protect. Tests can be a light; and tests can also be a shield.
—
For leagues reluctant to change, CTE is the bad news. It is that awful condition whose symptoms strike forty years before their time and make a person someone else. It is that terrible condition about which something simply must be done so that other players, and their families, don’t have to go through it, too. As a result, CTE has become the focus of the sports head-injury debate. But CTE is rare—or if it isn’t, we don’t know that it isn’t, and we won’t know that until a lot more players die and their brains are examined. So, for hockey players or football players, the problem—at worst, as far as we know—is a rare problem: sad, tragic, but a problem of relative one-offs.
For the unlucky ones and their families, the leagues will do more, whether of their own volition or nudged along by the pressure of class action lawsuits. The leagues will help those who suffer from CTE financially, and some day perhaps with medication and treatment, guidance and therapy as well, so that the athlete and their family can live the next forty years of life better. In time, perhaps, CTE might be turned from an urgent condition to a chronic one. Much as retired players today deal routinely with chronic knee and hip problems, one day they might deal with chronic depression and memory loss as a chronic brain problem.
The focus on CTE has shifted attention away from sub-CTE conditions such as depression, memory loss, and irrational behaviour, much as a knockout in boxing or an obliterating hit in hockey shifts attention away from frequent, sub-concussive, wear-and-tear blows to the head. CTE the red flag has become CTE the shield.
As a scientist, Ptito can study, he can learn, he can tell others what he has learned, but he is not a decision-maker. He cannot prevent. Only others can do that. As a clinician, one on one with his patients, he has more influence and effect. He cannot prevent their initial injury, but he can help to prevent their next one, and he can advise patients to stop their risky behaviour because the next one might be worse. Like Johnston, he finds this side of his work immensely satisfying. But to do his best for his patients, he knows that he has to be effective in terms of the big picture, too. Research and technology are expensive. Funders want big-picture payoffs; they want lots of people to be helped. He needs the NHL to do more because NHL players need to do better, and his patients do, too.
So he and Johnston keep telling their story.
CHAPTER TWENTY-ONE
Steve had not played for almost a year. Chicago could now send him to Rockford for up to fourteen days on a “conditioning loan,” to get him into playing shape. Or they could put him on waivers, which would allow every other team twenty-four hours to claim him, and his contract, with no compensation to the Blackhawks in return. If Steve were in Rockford
, or on the roster of another NHL team, Chicago would get some relief under the league’s salary cap, yet this late in the season they would have no opportunity to use that relief to acquire another player for their playoff run. Given Steve’s injury, his age, his contract, and because the Blackhawks no longer thought he could help them, they put him on waivers. No other team claimed him.
Now Steve had his own choice. He could see the demotion to Rockford as one more blow in a season full of very big blows, and put front and centre in his mind the headaches and depression he was experiencing so that nothing else in his life mattered. Or he could still pick up his same paycheque for the rest of the season and for two more seasons—not risk further injury, and not subject himself further to this psyche-crushing, soul-crushing cycle of hope and despair.
He could go easy and feel lousy. Or he could go hard and feel lousy. To Steve, why not go hard? Why not play? Why not hope?
Steve made his debut for the Rockford IceHogs on March 15. It was his first AHL game in more than nine years. He thought he could help the IceHogs in the way he had always helped his team: being aggressive, pushing, forcing, never letting up. But not having played in almost a year, he wasn’t so sure of what he could do and what he couldn’t. He didn’t have the same feel for the game, or for himself. But he was certain he could help the team off the ice, as the experienced veteran who had played more than 500 games in “the Show.” He had done what his new teammates had only dreamed of doing.
With the IceHogs, he would arrive early for practice and stay late, he would work hard and train hard, he would put all of himself into what he was doing, as if he wasn’t sorry for a second that he was where he was—and not where he wasn’t. And if he did, what right would his new, young teammates have not to do the same themselves?
