Love, Zac

by Reid Forgrave

  Zac seemed confused by the conflicting media reports he’d read about CTE in former football players. He didn’t know which sources to trust. That confusion had morphed into fear and anxiety. This young man, Spooner thought, is the exact type who can fall through the cracks and never get help. Spooner ordered an MRI to get a detailed look at Zac’s brain and brain stem to see if an image would show anything awry: a brain tumor, perhaps. From that very first appointment, it occurred to Spooner that Zac’s symptoms so many years after concussions could be a case of CTE, which can’t be positively diagnosed until after death, through an autopsy and studying the brain.

  But Spooner was cautious of drawing a simple straight line from concussions to postconcussion syndrome to chronic neurological impairment to CTE. Science takes time to come to a consensus. There was far from a scientific consensus on how concussions and subconcussive events affect the human brain, whose system of one hundred billion connected neurons has been called “the most complicated object in the known universe.” Any conclusion Spooner could come to about what Zac was experiencing inside his skull, and why he was experiencing it, was nothing more than a very educated guess. Maybe this young man really was experiencing an incredibly early onset of CTE. Or maybe it was something else. Most likely, Spooner thought, it was a nasty stew of many things: Zac’s brain struggling to recover from years of punishing football hits, but also his mental health and substance abuse issues, which may or may not be related to concussions. Science and medicine are messy and inexact, more art than math. What Spooner discerned from the five years since high school ended for Zac was that this sounded like a bad reaction to multiple concussions that were never properly treated. And this was the type of thing Spooner had become intimately acquainted with in the same period of time as Zac’s descent.

  Zac’s childhood had been remarkably similar to his new doctor’s. Spooner’s dad ran a John Deere dealership in their town of fifteen hundred people, where his mom was a dental hygienist. In high school, Spooner did it all: He ran track, acted in the school play, and played plenty of sports, from football to basketball to baseball. He was a voracious reader. It was a big moment when Sports Illustrated and National Geographic arrived on the same day. He worked his way up to the scientific treatises of Stephen Hawking. Football was his favorite sport. Just to field an eleven-man team in their district, players had to play both sides of the ball, so Spooner, all five-foot-eleven and 175 pounds of him, played center and nose tackle. The team was horrible. It didn’t matter; the games and even the practices were among the greatest times of Spooner’s life. “It’s just the cumulative experience of being on a team, with the guys,” Spooner told me. “Whatever, we weren’t good. But the experience wouldn’t have been any different.”

  He went to Iowa State University to become a physical trainer. His first two years he spent his time in the athletic training room, taping up Cyclone football players, setting up the whirlpool for basketball players, working the ultrasound machine to treat pain for wrestlers. But physical training was too static and monotonous for Spooner; he wanted to be where the action was, and the action seemed to be with the doctors. So he applied to University of Iowa’s Carver College of Medicine in Iowa City. “I grew up in a small town, and all we had was a family doctor,” Spooner said. “He did everything—casts, delivered babies, anything. This was what I wanted to be, the guy you go to when you need something.”

  But medical school is expensive. Something caught Spooner’s eye as he was looking through his acceptance paperwork: the Health Professions Scholarship Program. It was the summer of 2001, the end of a golden, conflict-free time in the US military. The United States hadn’t been in a conflict lasting more than six months since Vietnam. In exchange for free schooling, he committed to mandatory military service. Spooner picked the navy; his dad and his cousins had served in the navy, so why not? He attended the navy’s officer indoctrination course in Newport, Rhode Island, basically five weeks during which medical-school students learned to salute and to wear their navy uniform right, then reported to Iowa City for medical school. He spent one summer in a hospital in Boone, Iowa, living in an unused patient room, hanging out in the emergency room, and going on ambulance runs. When he graduated, a naval officer met him on the lawn outside the U of I’s Hancher Auditorium and promoted him to lieutenant. Along with his new bride, he reported to Camp Pendleton between Los Angeles and San Diego, one of the largest Marine Corps bases in the country, to complete his family medicine residency.

  During his second year, he was stationed on the obstetrics floor, delivering scores of babies. Late one night, a doctor he was working with mentioned he was part of the base’s sports fellowship program. Spooner spent the rest of the evening quizzing the doctor on the program, which seemed to marry Spooner’s two great interests: sports and medicine. After being deployed to South Korea for two years, where his second child was born, he returned to San Diego for the one-year sports medicine fellowship, then was sent to the Naval Station Great Lakes near Chicago, where he worked in the sports medicine clinic.

  One weekend in the fall of 2012, a few months before his required military service was up, Spooner, his wife, and their three children—the youngest had been born just weeks before—were visiting family in Iowa. They were going through a corn maze near Spooner’s parents’ home when his cell phone rang. It was his naval commander. His commander knew Spooner had only a short time left in his commitment, which meant he wasn’t eligible for a long overseas deployment. But the commander also knew there were only a couple of dozen sports medicine doctors in the navy, and one was needed in Afghanistan. The commander was to the point: “You’re up,” he said. “You don’t have to go. We’ll fight it for you. But it would be great if you went.”

  The military had paid for his schooling, and Spooner had served his required time. But he hadn’t really done anything operational. “It’s like being on a football team and standing on the sidelines,” Spooner said. “I wanted to be part of it. I felt like it was my obligation.” In a way, this was Spooner’s test of manhood. He looked at his wife, who held their new baby. It wasn’t a long conversation. “Yep, I’ll do it,” he told his commander. He had twenty-eight days before his departure. The next day, a real estate agent showed them five houses in Des Moines’s suburbs, and they put in a full-price offer for one. One box checked off before his nine-month deployment.

  Spooner went through predeployment training, brushing up on his firearms skills and learning how to burst into a house and clear a room. Then, on a dreary day in January 2013, he sat in a big, gray, windowless Boeing C-17 Globemaster III military transport plane alongside two hundred other military members. The flight from the staging area in Kyrgyzstan to the war zone in Afghanistan was somber. The landing was steep to avoid potential rocket attacks; it felt like the plane might crash. He arrived at Camp Leatherneck, the huge base in southern Afghanistan’s Helmand Province, the single deadliest province for the coalition troops since 2001. The doctor was at war.

  The military had been dealing with the effects of concussions on servicemen since World War I, when trench warfare introduced frequent use of high explosives and artillery fire, causing head injuries. Some World War I servicemen were diagnosed with shell shock, a catch-all term that encapsulated problems with memory and sleeping, and with headaches and depression. The scientific community at the time was divided, much like it is today, about whether physical injury was the primary cause of these symptoms, or whether they had more to do with preexisting mental health issues. Even then, the issue was clouded by politics. “Despite the lack of any pathological studies on the brains of individuals diagnosed with shell shock,” Ann McKee, one of today’s preeminent researchers into neurodegenerative disease, wrote with a coauthor in a 2014 paper, “wartime committees entreated with the responsibility to inquire into the entity declared the disorder to have psychiatric origins.” During the Persian Gulf War in the early 1990s, the word concussion was hardly uttered, but by
the first few years of the Iraq War about a dozen years later, concussions and traumatic brain injuries skyrocketed because of insurgents using improvised explosive devices (IEDs). At first the treatment was, essentially, here’s some ibuprofen, get back to work. But as wartime concussions ramped up, and as the fledgling science indicated these were brain injuries and not just someone getting his bell rung, the military started taking them more seriously.

  Not coincidentally, this occurred simultaneously with scientists like Omalu and McKee discovering that the long-term problems associated with concussions were far greater than originally thought. Two studies in 2009 and 2010 indicated that the prevalence of minor traumatic brain injuries—concussions—among returning service members was between 15.2 percent and 22.8 percent. Concussion was the most common battlefield injury, affecting more than three hundred thousand service members since 9/11. Once leaders realized the importance of taking brain injuries seriously, the military began medevacking concussed soldiers home for recovery, which not only left personnel vacancies but also cost the government money. So in 2011, the navy opened the Concussion Restoration Care Center at Camp Leatherneck. It was the first multidisciplinary concussion rehabilitation clinic in a war zone, treating soldiers during the acute phase immediately after a concussion. This was the center Spooner was selected to lead.

  The center’s concept was simple and revolutionary. Because the brain is such a complex organ, it means injuries are best treated by a team of medical personnel with different specialties. Spooner’s center did neurocognitive testing on each service member to establish a baseline before the deployment. In the event of a potential concussion, injured soldiers would be kept for observation for at least forty-eight hours. Spooner was the lead physician, the quarterback of the medical team, which also included a neuropsychologist, who worked on cognition, mental recovery, and stress and anxiety management; a psychiatrist, who managed medications; a physical therapist, who dealt with musculoskeletal issues like back, neck, and shoulder injuries; and an occupational therapist, who worked on balance, functional vision, and cognitive rehabilitation.

  Dr. Shawn Spooner led the Concussion Restoration Care Center in Afghanistan’s Helmand Province in 2013.

  Having all these specialists under one roof to treat concussion, a first for the military, worked. Between 2011 and the end of 2013, the Concussion Restoration Care Center treated about two thousand service members experiencing acute symptoms of concussion. Roughly 98 percent recovered within ten days and were sent back to their units. This was a huge positive for the military, and service members appreciated it as well. The sense of duty for an injured soldier who wants to return to his comrades is analogous to an injured football player eager to get back to his team: Both just want back on the playing field. At the Afghanistan concussion center, only thirty-two out of the two thousand people treated were sent home. The rest stayed on the battlefield. The most significant common factor of those thirty-two was that they had a preexisting mental health diagnosis before they were deployed and before they had a concussion. To Spooner, it appeared there was a correlation between existing mental health issues and taking longer to recover from concussion. Perhaps the link is something in the DNA, perhaps it’s situational, but certain people seemed more susceptible to major struggles after a concussion.

  Spooner noticed concussion recovery came in three buckets. The most obvious was physiological recovery—musculoskeletal problems, including neck and shoulder stiffness, headaches, sensitivity to light, alongside issues of balance and how you focus your vision. For doctors, this is easy to diagnose. A more difficult bucket to grasp is the metabolic recovery: How is brain chemistry changed by concussion or repeated subconcussive events? There’s research being done on animal brains to study what happens to a brain in the acute stage of a concussion. But it’s not like scientists can cut open a human brain and study it in the days after a concussion. “That’s something we just don’t know yet,” Spooner said. “If you really test people [who’ve been concussed] way past the time you’d assume they are ready to go back and play, you still have metabolic carryover that lasts longer than we thought it does. Does that mean they’re more vulnerable to head injuries later? We don’t know yet.”

  And then there’s the bucket of mental and psychosomatic recovery. The most severe postconcussion cases that Spooner has seen, the ones that last not weeks but months or years, have heavy undertones of depression and anxiety. Essentially, the concussion affects not just the patient’s brain but his or her mind. An innocuous trigger can make someone dizzy or nauseous or fall to the ground. For example, someone at a grocery store encounters a person pushing a fast grocery cart in his or her direction and flips out. The emotional response could be an expression of preexisting mental health issues made worse by the concussion; it could be a manifestation of post-traumatic stress disorder. For a doctor, the diagnosis is often guesswork.

  What Spooner doesn’t want is for hysteria to develop over football and concussions—a presumption that multiple concussions always lead to depression, then anxiety, then suicide, then an autopsy that diagnoses CTE. “Maybe they had protein tangles in their brain. Or maybe not. When I see people recover, I see them recover. Way more than 90 percent are better in a short period. But every concussion I see is different. It’s like snowflakes. They’re similar, they have similar features, but each one is different.”

  Just about every day during Spooner’s seven months in Afghanistan, his team would get new patients. Usually, it would be a group of soldiers whose armored fighting vehicle hit an IED. They’d undergo the same concussion screening in the field that football players receive on the sideline. If they tested positive, they’d come to Spooner’s center. One kid—a quiet teenage marine, straight out of high school and into the war zone—had recently arrived in Afghanistan when his vehicle ran into an IED. One of his buddies was hurt badly enough that he was sent home. The teenage marine had a concussion so severe that it took him two or three weeks at Spooner’s center to recover. Then, they discharged him, and he went back to his unit.

  A week later, the marine was on an isolated base staffed with soldiers from the country of Georgia; American troops were working closely with them. A suicide bomber drove a truck packed with explosives through the outer perimeter of the compound and blew himself up. The young marine was standing next to a helium tank, which exploded. That meant he was hit by the first blast wave from the original explosion and then, immediately after that, a second blast wave from the helium tank. The attack, which the Taliban took responsibility for, wiped out half the base. Seven Georgian soldiers died. The young marine was at the epicenter of mass trauma; that night, thirty-five Georgians and Americans were admitted to the one-room clinic with low lighting. It felt like M*A*S*H. Some had soft-tissue damage from shrapnel, but most were affected by the blasts’ shock wave.

  It was the most hectic night of Spooner’s deployment. Staffers brought out Sharpies and wrote results of concussion evaluations on injured soldiers’ forearms. Spooner can remember the look on the teenage marine’s face: A week after recovering from his first concussion, he’d gotten blown up two more times in a manner of moments. His eyes looked drunk: They were foggy, staring into space. His movements were slow. So was his cognition. “He just looked sad,” Spooner said. “It was more than just a concussion. It was like, What the hell is happening to me?” He stayed at the concussion center a while. Weeks passed. Service members were released when they showed improvement. But the marine wasn’t recovering at all. He was one of those thirty-two service members who got sent home.

  That marine stuck in Spooner’s mind. Where did his life go from there? Would he find himself in a VA hospital years or decades later still dealing with the aftereffects of this one June night in Afghanistan? When Spooner’s deployment ended and he returned to civilian life in central Iowa, he pledged to make treating concussions a central part of his sports medicine practice. Like he did in Afghanistan, Spooner constructed a
program that put all the needed resources to treat complex concussions on the same team. We too often think of medicine as the newest machines and latest pharmaceuticals. But oftentimes, the best medicine is about processes. For Spooner, it was a matter of concussion patients immediately having access to neuropsychologists, physical therapists, psychiatrists, and occupational therapists, not waiting weeks or months for proper treatment.

  Or, in Zac Easter’s case, years.

  When Zac walked into Spooner’s office six years after his final football concussion and said he was still experiencing aftereffects, Spooner thought of that young marine. He saw in Zac that same deer-in-headlights look. The loss of hope. The sense that something had been permanently altered inside his brain.

  So Spooner tried to give him hope.

  “I felt even more paranoid with what other people thought of me and sometimes I wasn’t sure if I was hearing stuff or not,” Zac wrote around this time. “I know I started to become psychotic some nights here recently because I feel like I’ve started to become delusional or I’ve been kind of hearing and seeing things. A few times I’ve gone down stairs and have asked the guys what they wanted because I sware I heard someone calling my name. A lot of this freaked me out because I’m not sure if I was going schitzo or not. I’ve felt like some days I’ve just been out of it. Over the years I’ve been starting to forget peoples names and just forget daily things. My roommates even joked about an alzhiemers commercial about an old lady losing her shit because I’ve felt like I’ve lost mine slowly.”