by David Klass
I am not supposed to use the names of the patients, so I’m just going to call them by letters.
“This is Mr. G,” Dr. Klapper said, loudly and clearly. “Hello, Mr. G, how are you today?”
The bald man turned his head a little to look at the doctor. It was weird, but you could almost see how hard he was working, to turn his head, to answer.
“Good,” he said, and his voice was a little bit thick. “I feel good.”
“I’m glad to hear it,” said Dr. Klapper. “Mr. G, I have two guests here with me today. Their names are Carla and Jerry, and they’re students who are interested in learning about our unit.”
Mr. G moved his head a little more, and I could see him focus on Jerry and me. I smiled at him, a little bit nervously, and he smiled back.
Dr. Klapper spoke again, same loud clear voice.
“Mr. G, do you remember where you are?”
“Hospital!”
“Excellent. And what day of the week is today?”
This took a few seconds, but he got the answer: “Friday!”
“Mr. G, do you remember who I am? Do you remember my name?”
Mr. G took his eyes away from me and concentrated on the doctor.
“I’m the guy with the loud ties who comes to see you every day,” Dr. Klapper said. “So what’s my name?”
“Doctor!” said Mr. G triumphantly.
“Doctor what?” There was a pause, and I felt really bad for Mr. G, since I could just tell, somehow, that he really wanted to get the answer right. Dr. Klapper didn’t let him try for very long, he just gave his own name like it was no big deal. “I’m Dr. Klapper,” he said, “and I’ll ask you again tomorrow, and I bet you’ll remember. Now, if you wouldn’t mind, can you tell our guests why you’re here?”
Again that pause, that kind of mechanical delay, while Mr. G turned to face us, met my eyes. I could see that his body was swaying a little more, and he reached out one arm and grabbed the walker to steady himself.
“Motorcycle!” he said.
“That’s right,” Dr. Klapper said. “You had a motorcycle accident. Very good job remembering! Okay, Mr. G, I will see you tomorrow. Look for the loud tie and remember, it’s Dr. Klapper!”
He turned and started walking away, and Jerry followed him, and suddenly I could see that they both moved like athletes—their bodies looked confident in space and powerful. I watched Mr. G for another few seconds, and I saw the physical therapist start to work with him again, encouraging him to slide his foot forward and take a step, still holding the walker.
The doctor led us outside into the hallway, where he told us that Mr. G was thirty-four years old and had crashed his motorcycle into a van. He had been in a coma for almost a week, and after he woke up, he hadn’t been able to walk or talk. “So he’s made tremendous progress,” the doctor said. “I don’t know how much he’ll get back in terms of memory, but he’s very motivated. He has two-year-old twins, and you should see how he lights up when his wife brings them in to visit. And she’s plenty motivated, too. She’s been redoing the whole house so he can come home. Taken out all the area rugs, anything that might trip him, made all kinds of modifications, decluttered the place.”
He took us into a hospital room, small and cramped, and introduced us to a lady who had been in a car crash. Then another room where there was a construction worker who had been hit on the head by a falling beam. With each of them, he asked if they knew where they were, if they knew what day it was, if they knew his name. The car-crash lady did know his name, and he congratulated her like she had just answered the hardest question anyone could ask. She had a huge flower arrangement sitting on her bedside table, and he asked her who had sent it. After concentrating really hard, she said, “Mom and Dad.”
The construction worker couldn’t talk very clearly, and there was some drool running down his face. On the whiteboard next to his bed, someone had taped up a big blowup of a wedding photo. I guess he was the groom, in a tuxedo, with his arm around his wife, in her wedding gown, about to cut the cake.
When we came out of that room and were standing in the hospital hallway, with nurses and physical therapists going by us, Jerry said, “Can I ask you a question?”
“Sure,” said Dr. Klapper. I knew he was going to tell us again how the construction worker had made a lot of progress, and I could see that he was hoping that we understood how hard these people were working.
“Is this really related to what happens when people get injured in sports?” Jerry asked.
Dr. Klapper nodded. “Brain injury is brain injury,” he said. “You’re looking at more extreme cases here, of course, but concussions impair all the same brain functions that are hurt in our patients here.” He smiled at us, maybe especially at Jerry. “I’m sure you’re aware of all the recent interest in sports and head injury,” he said. “All the controversy about concussion in the NFL, about professional hockey. Now they’re even looking at what heading the ball does to soccer players.”
I had read that, of course, but it kind of gave me a chill to hear it said by a brain injury doctor in this particular place, like he was reminding me that I had probably taken some hits to my own brain along the way. Still, I didn’t see how heading the ball could be anything like what I had seen happen to Danny Rosewood.
“It’s really shaking up professional football,” Dr. Klapper continued. “Back when I was training in medicine, we were never taught to expect the rates of chronic traumatic encephalopathy that we’re seeing now. I might have expected to see it in boxing, where the whole point is to injure the head, but no one ever told us that so many football players are so at risk. Jerry, I bet your team trains and drills with a whole lot more emphasis on good form and protective equipment than anyone was even imagining a decade ago.”
“It’s pretty intense,” Jerry said. “Put your head wrong when you tackle in a drill, and Coach makes you drop and give him thirty push-ups—and if there’s any horsing around without protective equipment, forget it, you get benched.”
“And they’ve outlawed spearing even in professional ball,” Dr. Klapper said. “They’ve done a certain amount to make it safer. But it’s still a violent game and people still get hit. Hockey, too. Same thing.”
“There are former pro football players now who are suing the NFL,” I said. “What kinds of effects do they have later in life?”
“Well, of course it’s hard to tell, decades later, which injury caused which problem. Remember, guys who play pro football mostly played high school football and college football, too. They spent years taking those hits, and they may have been most vulnerable back at the beginning.”
“Why is that?” Jerry asked.
“First of all, back when they were playing, like I said before, their coaches weren’t taking these risks seriously the way yours does now. They weren’t trained to save their heads, they weren’t watched closely if they banged their heads. And second, well, what we didn’t then understand is this: your brain isn’t done developing when your body reaches its adult height. You take a top high school athlete, a top college athlete, they’re as tall as they’re going to get, maybe as strong or as fast as they’ll ever be. You look at them and you think they’re fully grown, top of their form. But it turns out the brain doesn’t finish developing until your late twenties, so traumas and disruptions may injure it so that normal development doesn’t happen.”
Dr. Klapper gestured to a doorway a little further along the corridor.
“The last patient you’re going to meet is the guy I told you about, the hockey player. And this isn’t a typical injury—this is a worst-case scenario. That’s what we deal with here: worst case after a car crash, worst case after a workplace accident. So worst case for an athlete, well, reinjury is bad, but worst case is what we call second impact syndrome, so you’ll see the most extreme, but it’s generally true that an injured brain is a vulnerable brain. That’s why when I consult on athletes, I tell them they can’t even consi
der returning to play until they’re completely symptom free!”
“What kinds of symptoms?” Jerry asked. “I took a pretty major hit a couple of games ago, but I didn’t have any symptoms.”
The doctor looked at him, kind of close. “No headaches?” he asked. “No trouble when you study? Problems reading, memorizing, remembering?”
“Only trigonometry,” Jerry said, “and I’ve been having those problems since second grade.”
“I know what you mean,” Dr. Klapper said. “Calculus almost did me in when I was premed.”
You know, I get kind of irritated when smart people pretend to be dumb just because they’re jocks. It’s like girls pretending to be dumb because they’re pretty. I mean, give me a break. I decided to ask a question and interrupt whatever game they were playing. “So what other kinds of symptoms do people have when they’re just run-of-the-mill, not worst case, you know, when they aren’t as extreme as the patients you have here?”
“Their eye movements, lots of blinking, their concentration, their memory, their timing—all those things that show up in everyday life but also show up in sports. You know, there are times when I’ve told someone that no, he can’t go back and play, and I can just see he’s relieved. Sometimes they’ll admit that they know something’s off. But you know how it is, Jerry, you’re a quarterback. Sometimes they want to play so badly that they just go on kidding themselves that everything’s fine.”
He held up a finger in front of Jerry’s face. “Keep your head still, follow my finger with your eyes,” he said. He moved it all the way up, all the way down, all the way left, all the way right. “Good,” he said. “Did any of those movements hurt your head?”
“Really,” Jerry said, “really, I’m fine. I’m totally fine.”
“Let’s just go in this one last room and meet my hockey player,” Dr. Klapper said. It turned out to be the speech therapy room. The patient who was in there was the youngest guy we had seen. He looked like a college student, thin and kind of handsome, with very short thick brown hair and big brown eyes. But there was something off and just a little asymmetric about his forehead, like the right side was bulging out a tiny bit. He was in a wheelchair, with a neck rest propping up his head, facing a speech therapist, a woman wearing hospital scrubs and a jacket printed with letters of the alphabet, something you might imagine a kindergarten teacher wearing.
Once again, the doctor went through his routine of introducing us, telling us that this was Mr. L. The man in the wheelchair said nothing at all.
“Do you remember my name, Mr. L?” asked the doctor. The speech therapist held up a board covered with words and letters, and Mr. L moved a finger to point to the word yes.
“What letter does my name begin with?”
Again, the finger moved, and this time pointed out the letter K.
“Very good, Mr. L! Very well done!” Dr. Klapper sounded truly enthusiastic.
And then, right in front of the guy, he started to give us a little lecture on second impact syndrome. Mr. L, he said, was a varsity hockey player, very aggressive, very talented.
“As far as his coach knew, he’d taken a bunch of hits, but he’d never had a real concussion. But you know, hockey players can be even more extreme than football players. They think they’re warriors, they think you play through the pain, right?”
Dr. Klapper put his hand on Mr. L’s arm and squeezed it gently, through the hospital johnny. I was looking hard at the guy’s eyes—like I said, they were big and brown—and I tried to see if he registered the touch or reacted to what the doctor had said, but I couldn’t see any sign of it.
“In retrospect, we think he had probably had a string of minor concussions—maybe some he didn’t even realize were concussions—and then he’s in a close game, he gets checked into the boards, flips over, hits his head on the ice. I’ve actually seen the video, and it didn’t look terrible. Or not terrible for a hockey player. It took him a minute to get up, but he signaled to the coach that he was fine, and then, all of a sudden, he went crashing down again. And when they got to him, one of his pupils was already big, which means that his brain was swelling.”
It was a terrible, terrible story, and I couldn’t believe he was telling it right there in front of the guy. They took him to the hospital, and the surgeons actually had to take out part of his skull—that’s why his forehead still didn’t look even. But in a way the worst thing was that this had all happened months ago. The guy had spent two months unconscious in the hospital after surgery, the doctor told us, and then two more months when they weren’t sure he was going to be able to breathe for himself.
“He’s been with us for a while now,” Dr. Klapper said, and I swear he sounded proud. “And he’s come a long, long way. You can see how his hair is growing back where they had shaved it all off for the surgery. He can answer more questions week by week. We think there’s a real chance, given how young he is and how motivated he is, that he may recover speech. He works so hard—he never gets tired, he always wants to push a little farther.”
I couldn’t tell what on earth he meant, though I smiled my best encouraging smile at the good-looking vacant-eyed guy in the special chair.
When we were out in the hallway, and he finally wasn’t there in front of us, I had to ask, “Will he ever be normal? I mean, if he works hard, like you said, if he gives it more time, will he have a life?”
“He won’t have the life that he would have had,” said Dr. Klapper. “Like I told you, this is a worst-case scenario. You have to understand what happened in his brain, this second impact syndrome. Because there was already injury from all the previous hits, the brain doesn’t regulate properly. So there’s an additional blow, and it can even be a fairly minor one, but the brain just goes crazy, firing electrically, releasing neurotransmitters—those are the chemicals that carry signals in the brain—giving out alarm signals. It’s all the biological processes, electrical, chemical, blood flow, all happening supercharged at once, and the autoregulation goes haywire. We think that the capillaries, the tiny blood vessels, just allow too much fluid up into the brain. It leaks out, and if the brain starts to swell…” He paused. “You just think about that gelatinous brain in there, inside your skull, being stretched and pulled and banged,” he said. “And once you have an organ that’s already been injured … well, then it’s really vulnerable. And that poor guy got dealt a really bad hand. So you ask me, will he ever walk and talk, I’ll tell you, he’s young, he’s motivated, his parents love him, they’ll help out, but his memory, his cognitive skills, the speed of his processing—he’s not going to be back to anything like he was. Best case, and this would be really good, he’ll have speech that’s kind of slow and kind of slurred and that will also be true of his thinking. There’s been real injury done.”
After Mr. L, I had had enough. There was something so terrible about all these interrupted lives, Mr. G’s two-year-olds, Mr. L playing hockey in college, his parents, the construction worker’s marriage, the car-crash lady’s mom and dad. Dr. Klapper had called it second impact syndrome, what had happened to the hockey player, but it seemed to me that every one of these injuries had impact after impact after impact, infinite impacts on and on through the whole lives of the people who got hurt and their families. I couldn’t stand it.
“I don’t know if I could work here,” I told Dr. Klapper. “Jerry’s mom does physical therapy—she works on my knee, she’s really good—but this is different.”
“My mom works with lots of stroke patients,” Jerry said, surprising me. “She works on their walking, but some of them can’t talk, either. She says she first got into this from working with injured athletes, and she still does a lot of that, like with Carla—Carla’s a soccer star, by the way—but my mom says now she likes the elderly patients, too. She says there are lots of different kinds of strength and lots of different kinds of bravery.”
This is what I like about Jerry Downing, I have to say. Just when I think I have him
figured out, he says something or writes something that I would never have expected.
I was still thinking about that story of the hockey player who didn’t tell anyone that he had had concussions. So I asked Dr. Klapper another question. “People who have head trauma—traumatic brain injury—the important thing is, did they lose consciousness?”
“That’s one important thing,” the doctor said.
We were standing in a little corner of the corridor, the three of us grouped around a gray cart on wheels, with lots of drawers. I guess it was full of medicines. But I know enough to understand that there aren’t any medicines that give people back their speech, or their memories, or their ability to answer questions.
“So do people always know if they’ve lost consciousness?” I asked.
“Sure,” he said. “You ask someone, did it all go black, was there any time when you didn’t hear the people around you or see anything—they know.”
“Not always,” Jerry said. “I don’t mean like if a girder falls on your head, or something like that, but in some situations, like, say, a car crash that’s not so serious, or a sports situation, couldn’t you take a hit and have the wind knocked out of you and just not be sure if everything went dark for a few seconds?”
Dr. Klapper looked at Jerry hard again. They were almost the same height, and they both have this kind of square, open face. “Let’s step in here for a minute,” the doctor said, gesturing to the doorway in front of us.
We went in, and it was an empty patient room. There was a hospital bed, neatly made up, a bedside table, a blank whiteboard. All I could think was that one day soon, someone’s family photos would go up on the whiteboard, someone would be lying in that bed maybe not recognizing the people in the photos. It seemed like the saddest place in the world, that empty room, waiting for someone whose brain had gotten hurt, and I stepped over to the window and found myself looking out on a street eight stories down and a matching big building across the street. I wondered if that was also a hospital, and if there were more hurt people behind those windows, and my knee was aching, and I wanted to go home.
