The Concussion Crisis

by Linda Carroll

  Saunders and Harbaugh were haunted by the heartbreaking tragedy of an athlete inexplicably dying young. At the very least, they needed to be able to explain how such a minor jolt on the playing field could have killed a fit, healthy teen so quickly. While waiting for the autopsy report, they began to ask Montemurro’s family, teammates, and coaches about the weeks leading up to the fateful game.

  Teammates told Saunders and Harbaugh that Montemurro had been punched in the head during a fistfight four days before the game. He had briefly lost consciousness and went to the Cornell infirmary the next morning complaining of headaches and nausea. Doctors there told him that he had sustained a concussion and should avoid any contact sports until his symptoms resolved. The day before the Dartmouth game, Montemurro asked for medical clearance to play, insisting that his headaches had all but disappeared.

  These new details brought to mind a report Saunders had read a few years earlier describing the case of a college football player who died suddenly after a minor hit during a game. The eminent neurosurgeon who wrote the report suggested that that death might have been related to a concussion the player had sustained in an earlier game.

  When Montemurro’s autopsy results came in, it was clear there had been microscopic damage to his brain that predated the Dartmouth game by several days. That got Saunders thinking about an animal study he’d read years earlier. The study showed that once a certain pressure in the brain was reached, an irreversible sequence of events was triggered that eventually killed the animal. Saunders reasoned that the fistfight had raised the pressure in Montemurro’s brain to a dangerous but not fatal level and that the minor jolt during the game had pushed the pressure beyond the point of no return.

  The more Saunders and Harbaugh thought about the case, the more they realized its grave implications for all the young athletes playing America’s most popular sport. You didn’t need a big hit to kill a kid—a series of minor jolts could add up to a catastrophe. Saunders and Harbaugh wrote up their findings to warn doctors across the nation about this unrecognized threat. Wanting to reach the broadest possible audience, they submitted their paper to one of America’s most prestigious medical journals. The two-page article, published in the Journal of the American Medical Association in 1984, introduced a syndrome that Saunders and Harbaugh dubbed “second impact.”

  The warning was clear: second-impact syndrome could occur any time an athlete suffered a jolt to the head too close on the heels of an earlier concussion. If the brain didn’t have enough time to recover from the initial concussion, a second one could have a much more devastating impact—even when the second resulted from nothing more than a light tap. That second hit could cause the brain to swell catastrophically. But it was the first hit, Saunders and Harbaugh discovered, that had made the player into a walking time bomb.

  Saunders and Harbaugh’s little paper had a big impact on doctors like Robert Cantu. As he walked the sidelines, Cantu realized that if he missed a concussion today, some kid might get bumped next week and die.

  Cantu wasn’t worried just about the kids playing right in front of him. He was thinking about all the kids playing across the nation. He knew that precious few states required sideline physicians as Massachusetts did; few required even an athletic trainer at games. Cantu figured the best way to protect kids from second-impact syndrome was to draw up a set of guidelines that could help coaches and medical personnel figure out when and for how long a concussed player should be sidelined.

  At the time, there was no real science to guide him. There weren’t studies to show how long it took concussed athletes to recover; there wasn’t even a consensus among experts on the definition of a concussion. Cantu could only draw on his more than twenty years of clinical experience diagnosing and treating concussions, not just in athletes injured on the playing field but also in patients who came to his office after falls, car crashes, and other accidents. What he came up with was a set of guidelines linking the severity of concussions to the length of time a player should be sidelined. An athlete with a “moderate concussion,” for example, could return to play one week after symptoms had completely dissipated, whereas a “severe concussion” would sideline a player for at least a month.

  When Cantu’s guidelines were published in the October 1986 issue of The Physician and Sports Medicine, there was finally a reference for people trying to manage concussions. While Cantu was the first to admit that his choice of suggested recovery periods was “pure seat of the pants,” he figured that they would at least make the point that concussions were serious business and that players often needed to be sidelined.

  Moreover, the very existence of a published set of guidelines would send the message that doctors might be able to prevent deaths from second-impact syndrome. Just in case his fellow physicians weren’t as scared as he was by the specter of a second-impact death occurring on their watch, Cantu reminded them that lawyers also read journal articles like his. The clear implication was that malpractice lawsuits over poor concussion management were now possible because there was proof that letting a kid come back before his brain had healed could lead to his death. As Cantu traveled the country explaining his guidelines and preaching his gospel that everyone should err on the side of caution, he would drive his point home with his favorite mantra: “When in doubt, sit them out.”

  The guidelines had far less impact on the medical community than Cantu had hoped. Kids with significant concussions were still being sent back into the same game in which they’d been injured. Kids who’d been sidelined were returning to play while still symptomatic from concussions suffered weeks earlier. And every parent’s worst nightmare was still occurring: kids were still being killed by concussions.

  Parents would be reminded of the danger whenever the tragic story of a schoolboy dying after a minor hit cropped up in the local newspaper. On Long Island, seventeen-year-old Billy Rideout played through a concussion sustained in a 1986 high school game, collapsed two weeks later on the sideline right after another hit, and died three weeks afterward without ever regaining consciousness. In West Texas, seventeen-year-old Gabriel Sanchez suddenly collapsed and died after suffering his second concussion of the 1988 season. In Southern California, seventeen-year-old Freddy Mendoza shrugged off headaches from a concussion that knocked him out of a 1991 game, collapsed after a hit in the following week’s game, and died two days later.

  Though it grabbed headlines and hearts whenever it struck, second-impact syndrome was nevertheless a relatively rare phenomenon. The CDC documented seventeen deaths from the syndrome between 1992 and 1995, though its report cautioned that this could be an underestimate. All the deaths were in young athletes, mostly teens. That didn’t surprise brain injury experts because immature brains were known to be more vulnerable to concussions in general.

  Although second-impact syndrome didn’t always kill, it was always devastating. The aftereffects would plague survivors like Brandon Schultz for their entire lives.

  Schultz was a high school sophomore in 1993 when a jarring collision in a junior varsity game briefly knocked him unconscious and sent him to the sideline with a headache so bad that he was grimacing and screaming in pain. Although he continued to complain of headaches all week, none of his coaches ever suggested that he see a doctor or get medical clearance before returning to play—a standard practice in his Anacortes, Washington, school district for even the most minor orthopedic injuries, but not for head injuries. Back in action on the defensive line just a week after the concussion, Schultz made a routine tackle on the last play of the first half. Ten minutes later in the team’s halftime huddle, he dropped to the ground convulsing in seizures and lapsed into a coma. He was rushed to the hospital, where doctors discovered that his brain was swelling rapidly and performed the first of four emergency surgeries to reduce pressure on it.

  Schultz survived, but with severe brain damage that left the onetime A-student cognitively impaired, partially blind, and physically disabled. With no
hope of ever living independently, he was transferred to a long-term-care facility in California. Schultz’s family sued the school district on his behalf for neglecting to institute a concussion policy. In a landmark settlement in 1998, five years almost to the day after his life-altering concussion, the school district agreed to pay for the medical care and rehab services Schultz would need for the rest of his life—an estimated $12.6 million.

  Despite its catastrophic consequences, second-impact syndrome was easy for athletes to rationalize away: they figured it was so rare that they were more likely to be run over by a car than struck by second-impact syndrome. A far more prevalent problem would be harder to dismiss. It was becoming increasingly clear that repeated hits to the head could lead to lasting symptoms even when concussions came months or years apart. And if you were among the millions watching America’s most popular spectator sport on any given Sunday, it was impossible to miss this phenomenon.

  • • •

  With a berth in the 1994 Super Bowl on the line, Troy Aikman wasn’t about to let a little thing like being kneed in the helmet by a 290-pound lineman deter him. So the Dallas Cowboys quarterback picked himself off the ground after the crushing tackle and played out the series of downs as if nothing had happened. When he returned to the sideline and started talking gibberish, the team trainer asked if he was OK. “Fine,” Aikman shot back. But twenty seconds later, it was clear he wasn’t fine. “Give me some smelling salts,” he told the trainer. “I’m a little fuzzy. Something’s not right.” After Aikman began asking what day it was and who the Cowboys were playing, the team doctor diagnosed a concussion and sidelined the superstar quarterback for the rest of the afternoon. When the game was over, Aikman was sent to the hospital for overnight observation as a precaution.

  Later that night, his agent, Leigh Steinberg, drove over to Baylor University Medical Center to visit Aikman. As Steinberg made his way through the streets of Dallas, he was struck by the intensity of the city’s impromptu celebration: fireworks were booming, horns were honking, fans everywhere were shouting and screaming. The revelry outside contrasted sharply with what he found in the hospital room. It was dark and silent, and Aikman was sitting alone, looking confused and oblivious. As Steinberg made his way over to the hospital bed, his twenty-seven-year-old client’s boyish face brightened.

  “Where am I?” Aikman asked.

  “You’re at Baylor,” Steinberg replied.

  “Was there a game today?” Aikman wondered.

  “Yes,” Steinberg nodded.

  “Did I play?”

  “Yes.”

  “How’d I play?”

  “You played well.”

  “Did we win?”

  “Yes.”

  “Where does that put us?”

  “You’re gonna go to the Super Bowl.”

  Aikman’s blue eyes lit up and a big smile spread across his face, and then the conversation moved on to other topics. Five minutes later, Aikman paused and asked, “Where am I?”

  “You’re at Baylor,” Steinberg answered hesitantly.

  “Was there a game today?” Aikman queried.

  “Yes.”

  “Did I play?”

  “Yes.”

  “How’d I play?”

  “Well.”

  “Did we win?”

  “Yes.”

  “Where does that put us?”

  “In the Super Bowl.”

  Aikman’s face brightened into a big smile, and he moved on to another subject. A few minutes later, he again asked Steinberg, “Where am I?” That touched off an instant replay of the exact conversation they’d already had twice. Steinberg was shaken. He had never seen anything like this, and he was worried about what would happen when he left the hospital and was no longer around to answer Aikman’s questions. Finally, Steinberg decided to write all his answers down on a sheet of paper so he could leave it on the bedside table when visiting hours ended.

  The next day, Aikman flew with his teammates to Atlanta for the Super Bowl. During the week leading up to Super Sunday, he was plagued by headaches and nausea. When Steinberg called to check up on him, Aikman again sounded confused and seemed to think he was still playing for the Henryetta Fighting Hens, his old high school team back in Oklahoma.

  Even though Aikman led the Cowboys to their second straight National Football League title that Sunday, he wasn’t the same quarterback who had dominated the previous Super Bowl with the clockwork precision of a field general. Afterward, while watching Aikman struggling to recall any plays from the game, Steinberg couldn’t shake a feeling of foreboding. Though his marquee client had managed thus far to come back from his concussions, other players hadn’t been quite so resilient.

  In the fall of 1992, one of football’s most electrifying stars, Al Toon, had been forced to retire prematurely by a host of debilitating post-concussion symptoms that wouldn’t ease off. Initially, the concussion that knocked Toon out of the NFL didn’t faze him any more than the previous eight. A wiry All-Pro wide receiver who’d awed New York Jets fans for eight seasons by making acrobatic catches and withstanding brutal hits, Toon expected to bounce right back from a tackle he didn’t think was particularly hard. He shrugged off the usual headaches, dizziness, and mental fog, figuring the symptoms would disappear after a couple of days just as they had after all his previous concussions. But this time, the symptoms tenaciously hung on and then got even worse. He was experiencing memory loss, vertigo so bad he couldn’t stand up in the shower, headaches so intense he needed to spend whole days bedridden in a darkened room. Toon went from specialist to specialist in search of relief and answers. None of those doctors could tell him how long it would take for his symptoms to abate or if he’d ever fully recover, but they all agreed that he shouldn’t risk another blow to the head. Three weeks after his last concussion, Toon tearfully announced his retirement at the age of twenty-nine.

  With that retirement, a new concept entered the sports lexicon: post-concussion syndrome. Toon’s story provided a textbook case to illustrate how repeated concussions could lead to a syndrome in which symptoms take longer and longer to ease. It also provided a frightening example of how long the syndrome’s classic symptoms—headaches, dizziness, fatigue, mental fogginess, memory loss, irritability, depression—might dog a player.

  By the night in 1994 when Steinberg visited Aikman in the hospital, Toon had already been battling his crippling concussion symptoms for more than a year. Steinberg couldn’t help but think of the retired player’s plight as he spoke with his own bewildered client. He started to wonder how many concussions Aikman’s brain could withstand before he wound up in the same situation as Toon. He worried about all the other players on his deep, star-studded client roster—especially the quarterbacks. As the superagent who represented half the starting quarterbacks in the NFL, he knew they were the most vulnerable to the kind of hits that led to severe concussions.

  Over the years, Steinberg had become increasingly troubled that the defensive linemen and linebackers who targeted his quarterbacks on every play were growing bigger, stronger, and quicker. Aikman, the prototypical drop-back passer at six foot four and 219 pounds, was easy prey for linemen a hundred pounds heavier than he was.

  More worrisome was the situation with Steinberg’s other superstar quarterback, Steve Young. As if it wasn’t enough that he had already played five seasons longer than Aikman had, Young was even more vulnerable to hard tackles because of his bold scrambling style. A peerless all-around athlete at six foot two and 205 pounds, Young could dominate not only by rifling precise passes but also by darting away from charging linemen and bolting downfield with would-be tacklers in pursuit. On one characteristic play, he ignored teammates’ pleas to safely run the ball out of bounds after his helmet came off and instead dashed downfield with his bare head exposed to the headhunters—in a meaningless exhibition game, no less. While Young’s fearless and reckless play for the San Francisco 49ers made him the NFL’s top-rated quarterb
ack, it also put his brain in harm’s way dozens of times every game.

  Steinberg remembered the first time he broached the subject of concussions with Young. They were having dinner in a Bay Area restaurant one Sunday night after a game. Steinberg waited for a quiet moment, leaned forward, and asked, “So Steve, I’ve been wondering, how many concussions have you had?”

  “Do you mean official ones?” Young responded.

  “What’s an official concussion?” Steinberg asked.

  “Well, an official concussion is when you’re knocked out and they cart you off the field and they use smelling salts to revive you.”

  “So what’s an unofficial concussion?”

  “That’s when you’re dazed or stunned and you’re not quite there, but you can still play. You’ll be impaired like that many times during the season.”

  “So how many total concussions does that make?”

  Young shrugged and then said, “I couldn’t even count ’em.”

  Steinberg found the whole exchange disconcerting. As he left the hospital the night of Aikman’s third “official” concussion, Steinberg’s brain kept bouncing back and forth between that exchange with Young and the disturbing visit he’d just had with Aikman. The more times Steinberg replayed those two conversations, the queasier he felt. He had just negotiated the richest contracts in NFL history for Aikman and Young, but he was now coming to the conclusion that no amount of money could compensate for the risks they were taking. At that moment, Steinberg decided that an agent owed his clients more than just making them big bucks. He would do for them what they wouldn’t do for themselves: protect their brains.

  Steinberg started accompanying Aikman and Young to their doctors’ appointments. He would come armed with a series of questions for each neurologist: “How many concussions are too many? What are the possible consequences of all these concussions? At what point do these multiple concussions start to imperil an athlete’s ability to live a normal life once he gets out of the sport?” It soon became clear that none of the doctors could answer his questions, and that only made Steinberg more nervous.