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As
the medical director of National Sports Medicine
Orthopedic Group, P.C., and assistant team physician
for the New York Giants, it is easy to see how
Dr. Stephen O'Brien keeps quite busy. However,
when you consider that he is also the chief
orthopaedic consultant for St. John's University,
medical director for the New York Racing Association
and head team physician fo rthe New York Rough
Riders Professional Soccer Team, New York Saints
Professional Lacrosse Team and the USA Junior
World Lacrosse Team, one can only speculate
about when this gentleman sleeps! On a recent
afternoon, I had the pleasure to meet with Dr.
O'Brien at his offices in New York. During that
time he shared his perspectives on orthopedic
medicine and surgery and his perceptions of
their association with traumatic stress.
JSV: Dr. O'Brien, can you
tell me about your current positions and/or
roles. I understand that, in addition to your
orthopedic practice, you regularly treat professional
athletes.
SJO: I am currently the assistant
team physician for the New York Giants, with
my partner, Dr. Russell Warren. Dr. Warren has
been the head physician for the Giants for about
fifteen years. I started with the Giants in
the first year that they had gone to the Super
Bowl (1986). I was a fellow at the time. That
was a lot of fun. In the last few years, I have
taken on a more active role on the staff of
the Giants. I am also the head orthopedist for
St. John's University, the head orthopedist
for the New York Racing Association, head orthopedist
for the New York Rough Riders Professional Soccer
Team (Men's and Women's Team), head orthopedist
for the New York Saints Professional Lacrosse
Team, and the head team physician for the USA
Junior World Lacrosse Team. Moreover, I unofficially
take care of a lot of the high schools throughout
the area. So I have a pretty full plate. I am
affiliated with the Hospital for Special Surgery
(HSS)-Cornell University Medical Center and
North Shore University Hospital at Glen Cove.
Dr. Warren has been my mentor.
I trained under Russ, did a fellowship under
Russ, and have been his partner for about eleven
years. The first time I met Russ was in 1980.
It is kind of an interesting story because he
was the only one that I had ever met that had
anywhere near the same enthusiasm for Sports
Medicine as I did. I came up as a student (to
HSS) from the University of Virginia. He had
started his practice in Virginia before he came
to Cornell. I ran into his partners when I was
a student down there and told them that I loved
sports medicine. They told me to look up their
former partner who was now at HSS/Cornell. I
was doing, at that time, a rotation at HSS in
radiology and I wandered down to the sports
clinic one day. At that time, sports medicine
was considered very taboo and not mainstream.
I ran into Russ at the clinic. He was seeing
patients with the residents. Well, needless
to say, I looked around at 7:00 PM and everyone
else had left an hour before. We began talking
about sports and medical problems. The interesting
thing was that our meeting told me that this
was exactly what I wanted to do and this was
the guy that I wanted to do it with. I ultimately
trained under Russ, who is an outstanding doctor
and probably one of the most pre-eminent sports
physicians in the world. I always felt that
sports medicine wasn't getting proper attention
with regard to the scientific aspects of making
performance better. Up until then, people didn't
really think it was a field or that it should
be pursued. It is all about how to improve human
performance. The issues in athletes are different
than issues in other people. In trying to get
athletes better as quickly as possible, we have
made the treatment of the non-athlete much better.
Thus, people can get back to the workforce,
for example, much quicker, better and safer
and with smaller invasive surgery.
JSV: The American Academy
of Experts in Traumatic Stress is an organization
that recognizes that professionals from different
disciplines work regularly "on the front
lines" with trauma survivors. Moreover,
it is in this spirit that the Academy attempts
to increase providers' awareness about the emotional,
cognitive, and behavioral effects of traumatic
events and facilitate early intervention. What
have been your observations of the emotional
well-being of patients who have sustained life
threatening injuries or threat to their personal
being?
SJO: There is no question that
a patient's emotional and psychological well
being have an enormous effect on treatment outcome.
I can't tell you at the cellular level what
is happening but I know that there are many
studies looking at psychological well being
and life traumatic events and subsequent effects
on cancer and other medical problems. If you
have a person who has experienced a traumatic
event and you address their psychological well-being,
communicate well with them, and make them a
participant in the team, then they appear to
do much better. There is no question in my mind.
In my field, I find that women (not to be disparaging)
actually do much better than men, in general,
for a number of reasons. They don't come in,
typically, with the same ego problems as men.
They tend to be more cooperative. They handle
pain better (this may be psychological as well
as physical). Moreover, women may not be as
tight-jointed because of the different levels
of estrogen and other hormones. Thus, their
recovery tends to be quicker. They don't tend
to be as controlling as men patients. Now, obviously,
I am a man and I don't want to "diss"
men but I only use this as an example to illustrate
the importance of working collaboratively with
a team as one recovers. I don't want to make
a blanket statement but I use this gender example
to demonstrate how anyone who has their emotional
and/or psychological well-being in place can
do better.
JSV: Can you reflect on
any patients, in particular, who stand out in
your mind as especially having been difficult
as a result of the emotional aftermath that
ensued as a result of their orthopedic injury?
SJO: Well, I have had a number
of different patients who have had concomitant
emotional issues. For example, there was a young
woman who was hit by a car. She had dislocated
her knee and had torn every ligament. She had
ongoing problems with her parents. She was in
a bad emotional state at the time and in fact,
was hit by the car after she ran into the street.
Following the injury, a traumatic event for
her, there was a lot of emotional tension with
her parents. I really think she was quite distracted
from concentrating on her knee and on the fact
that she was about to face major surgery. Following
the surgery, she had experienced more difficulty
in her ability to regulate her emotional state
and physical pain. She wasn't fully on board.
We helped her to get psychological counseling
and did some counseling with the parents and
got everyone to collaborate in her treatment
to facilitate the emotional and physical healing.
I saw her about a month ago--five or so years
after the surgery--and she is doing perfectly.
What we needed to do in this case was have early
intervention to address the emotional distress
so that she could focus on her knee. We were
initially going backward. When she was able
to develop a better frame of emotional and cognitive
functioning, she came around much quicker. I
never operate on a patient who is not psychologically
prepared for surgery. I tell patients that if
they walk in backwards then they are going to
walk out backwards. Patients have to be mentally
prepared and I tell people to wait until they
can be an active participant in their treatment.
We see this a lot in adolescents whose parents
tell them to have surgery. I can sense when
the child is not ready and I will wait until
that person is on board emotionally, cognitively,
and physically. Moreover, you can never guarantee
against things like infections, scar tissue,
etc., and the patient has to be ready for such
potential side effects of surgery.
JSV: Whenever I watch athletes,
especially football players or gymnasts, I think
to myself about the physical toll that their
livelihood is having on their body. For example,
I know that the most elite female gymnasts find
their careers are over by age twenty. How do
you address patients about the serious, potentially
life-threatening danger that they might experience
in continuing with such rigorous activity?
SJO: That is a good point.
I'll take professional football for an example.
The athletes in this situation are dealing with
injuries that are certainly limb-threatening
(and potentially traumatic for them) and/or
can create a permanent disability. One of the
keys is to make sure that you communicate on
many levels. We are extremely lucky to have,
as head trainer of the New York Giants, Ronnie
Barnes. Ronnie is one of the best communicators
that I have ever met. So, for instance, I am
talking to an athlete and I am conveying what
I think is a very logical explanation for assessment
of risk only to find out that the athlete didn't
follow anything that I was saying! Ronnie, who
is the head trainer, did, but the athlete did
not. Ronnie can take that information and convey
that more effectively to the athlete. The athlete
can then become more comfortable in discussing
various things including their fears, worries,
etc. to the head trainer that they may not otherwise
discuss with me or any other physician. Whereas
they may be hesitant to tell the doctor that
they don't understand, they wouldn't hesitate
to talk with the trainer. We open up the lines
of communication and attempt to get the message
across so that the athlete can make a better
and educated decision, as well as reduce anxiety
associated with the incident. Communication
is key to their performance and their physical
and emotional well being. It is incumbent upon
the physician who works with athletes (and patients
who are injured, in general) to facilitate the
long-term view (e.g., what the effects of continued
play could be in twenty years) as opposed to
the immediate view (e.g., "I got to be
in the game and play this week!").
JSV: When discussing with
a patient the possibility that they may never
walk again or the discovery of degenerative
bone disease, for example, we can look at it,
psychologically, as a patient's confrontation
with an unknown or unpredictable outcome. With
regard to traumatic exposure, we often discuss
threat to an individual's sense of security
and well-being. What are your observations about
how people react upon such unfavorable prognoses?
SJO: They are all over the
map! We have some patients who are in complete
denial. Some patients are more accepting of
what you propose. Let's take a patient who has
to undergo an amputation or, for example, one
of my patients who had 28 operations before
he saw me and needed a knee replacement. Unfortunately,
because of so many surgeries, the risk of infection
is increased. He developed an infection and
the prosthesis had to be taken out and he was
not able to have it go back in. He was set on
having the re-implantation when I knew it couldn't
be done. He actually might have been better
off with an amputation than with a lower leg
that was not very useful. Some of the things
that have been done with amputees allow them
to go back to being very successful athletes.
Well, I have not been able to get to a point
to help this patient see things clearly. Once
he can see the situation clearer, he can then
make some decisions. For example, he may choose
to walk with a brace (which he is now rejecting),
have a knee fusion (which is another option),
or consider having the amputation and attempt
to move on with his life. In many ways, he may
end up functioning better with a prosthesis
than with a knee fusion. With a knee fusion,
the knee remains permanently straight and there
are other problems he could encounter. Our goal
is to get the patient to be a "non-patient."
We don't want them to be patients forever. The
decision to amputate a limb and attempt to get
on with one's life is a "quality of life"
decision and not an easy one to make.
JSV: There is a growing
recognition that those who deal with traumatized
people, including psychotherapists, emergency
care workers, nurses, physicians, and other
caregivers, may all be subject to secondary
traumatic stress reactions. That is, through
their efforts to help a traumatized population,
the helpers themselves become overwhelmed and
are traumatized indirectly or secondarily. Do
you see such risks for health care personnel
in a clinic setting?
SJO: There are circumstances
in which you do not win every battle and they
certainly have an impact on you. There are risks
that healthcare providers take as well. For
instance, I had a young fellow who was a great
young athlete being recruited by a number of
schools. He was a tight end, 6'3", 245
pounds and had the world by the tail. He had
an ACL reconstruction (Anterior Crucia Ligament--a
ligament in the knee for stability) which is
a common operation that we do. Most people usually
do extremely well. We had planned to fix his
knee and get him going for the fall (to Princeton)
with a possible professional career in football.
He, unfortunately, ended up having a devastating
infection. He had an extremely stiff knee and
was never able to compete in football again.
Although we felt like we did all the right things
and managed his care in all the right ways,
sometimes we can't win every battle. I can tell
you that I still feel terrible to this day that
it never happened for him. I have been fortunate
that I have not had many patients die under
my care. Does this affect my everyday life?
No, but it certainly does add stress because
of the risks that you take with the patient
in your effort to help them.
JSV: How do you handle informing
a patient of the extent of their injury? For
example, how do you tell a patient who has experienced
severe orthopedic injury (e.g., a gunshot wound)
that they may never feel the same way again
or have the same mobility as they had before
the injury? How do you cope with the patient's
fears of the unknown?
SJO: You need to be very direct
with the patient. It is incumbent on the physician
to help lower anxiety and help the patient achieve
a level of understanding. There are very few
situations where you can't help the patient
feel some optimism. I think to delay telling
the patient what you think is going to be the
outcome is wrong. For example, I may come out
and say, "This is a serious problem and
you are faced with a situation that may not
be entirely recoverable." You should never
try to cut out hope. You should identify the
problem and start talking about solutions immediately.
There are a number of patients who will have
lifelong problems. What I always try to do is
help them feel good enough to realize that,
although they won't be able to do certain things,
they may have no problem doing other things
and, hopefully, still be happy. I think that
it is important that you stick with them and
quarterback the situation for them. They should
never feel that you will abandon them. In other
words, you act as their partner and help them
to be as good as they can be. You must show
that you are committed to helping them. It is
amazing how patients feel when they know that
you will be with them all the way. You have
to be an effective communicator. I pride myself
on being an effective communicator. You have
to look at your patients' verbal and nonverbal
responses and listen to your patient. They may
tell you one thing but you may read in their
face that they don't really mean it or feel
it. Also, it is important to inquire as to how
well they understand what you are saying. Make
sure you address all of their questions. Most
of the time when I ask a patient, prior to surgery,
"How are you doing"? they say, "I
am nervous and I am frightened as hell."
I usually tell them, "That is O.K. and
this is normal." In fact, I may further
validate their feelings by saying, "If
you weren't afraid, then there is really something
wrong here." All of a sudden, they seem
to feel better. When a patient says, "I
am terrified of the surgery," I'll say,
"Well, you know what, that helps me tremendously
because I now know that I will have to spend
a little extra time with you early on to make
sure that you are more comfortable." People
should not feel as if they are crazy because
of their fear.
JSV: In many professions,
working with children in distress has considerable
potential to evoke a variety of feelings. How
do you manage your feelings when dealing with
a child or adolescent (e.g., the high school
athlete) who has experienced significant physical
trauma and may be permanently disabled from
the incident?
SJO: The high school athletes
are my favorite patients. Their eyes are wide
open. They are typically full of optimism with
regard to their own physical capabilities and
with whatever they may want to achieve, whether
it be going to a certain college or career,
etc. I think one of the most important things
we must try to avoid is dictating to the child,
especially the adolescent. You can't come on
too much as an adult. If you let them know that
you are there to help them and that you know,
at times, things won't be easy, then they actually
do really well. I enjoy talking to the high
school athlete and have had the pleasure of
watching many of these patients go on to do
very successful things. When you take on patients
like this, you tend to bond with them. They
become a part of you. I have been fortunate
to play a role even in the careers of some of
my patients. For example, I have had some of
my adolescent patients with interests in medicine,
who were operated on by me, come back and observe
me in surgery. One of the residents at the hospital
has been following me around since high school.
He was a patient, then a friend, and now an
associate. This has been quite exciting for
me professionally and personally.
JSV: As you know, the American
Academy of Experts in Traumatic Stress, is unique
in that it is a multidisciplinary network of
professionals who are committed to the advancement
of the intervention for survivors of trauma.
This includes increasing the awareness of the
effects of trauma and improving treatment. In
what ways do you think physicians can contribute
to increasing awareness about trauma and, hopefully,
improve treatment for trauma survivors?
SJO: Again, I will say that
communication is key. One of the things that
we try to do, whether this be in helping the
injured athlete or working with the severely
traumatized patient, is create a team concept
in which the patient is an active participant.
You want effective communication to ultimately
improve functioning. We can help patients move
past medical problems by addressing more of
the emotional/psychological issues related to
trauma. We must make them part of the treatment
team to ultimately help them improve performance
in many domains. With the severely traumatized
patient, you must make sure that you are on
the same wavelength with the patient and the
family. I always try to encourage patients"
families to be part of their care. I never disallow
family members or significant others from being
in the room for the patient. These family members
are part of that patient's team and I have nothing
to hide. Some physicians really don't like a
crowd around, but you know, all of that crowd
are participants in the recovery. It is that
crowd that will help move that patient forward.
Sometimes I will sit down with a family and
give them hell because they are either too hard
on the patient or too hard on "the system."
In other words, they may alienate their child,
for instance, by telling them that they are
not trying hard enough or smother them and do
all of the talking for them. Sometimes the families
may sit and ask the physicians and therapists
to verify and/or validate everything that they
are saying--this sets up a mistrust. Such mistrust
is not productive for the patient, physician
or therapist. Trust of the health care provider
is essential. Sometimes I have to attend to
the parents' anxiety first before I can be helpful
to the patient. At times, parents (and/or caregivers)
need to modify their behavior to, ultimately,
be most helpful to their child.
JSV: As a physician working
with orthopedic patients, are there any suggestions
that you could give with regard to helping victims
of traumatic events?
SJO: What you have to do first
is have the patient deal with reality. You don't
take away their hope but you may have to stop
their pipe dream. I see a lot of patients who
have had severe physical trauma and have developed
a very painful condition known as Reflex Sympathetic
Dystrophy. Many of these patients have gone
from doctor to doctor and they are very frustrated.
They are waiting for that one person who has
that magic bullet. I spend my first couple of
sessions dedi-cated to convincing them that,
even if they get better, it is going to be a
year or more; they need to understand that they
must reset their clock. Once they do, then they
can move ahead and we can be productive. They
have to know that they are not going to wake
up one morning and be cured. We need to work
as a team. The first thing may be getting a
consultation with a psychologist or psychiatrist
to deal with the emotional toll that the injury
has taken on them (perhaps, especially when
the injury is unexpected and overwhelming for
the patient). They need to understand that they
may not see any results for a long period of
time. Moreover, in some cases, they may need
to realize that they will never be normal and
help them accept and manage emotionally with
that so we can help them to move forward. For
example, with the paralyzed patient, this may
mean getting them to sit up in a wheelchair
and work to maximize whatever they can and find
domains in which they can succeed. A great example
of this and a tremendous inspiration is Mark
Buonacotti, the son of the former professional
football player, Nick Buonacotti. Mark was paralyzed
playing football. He, with his family, did a
number of great things. They went through their
grieving process and then decided to fight back.
For instance, they set up the Miami Project
to cure paralysis, along with Dr. Barth Green
and Dr. Frank Isemont. In the first year or
two, I noticed that Mark could barely talk.
Over the course of time, not only has he become
an eloquent public speaker, advocate for his
cause, and inspiration for many people, but
he and the Institute have also raised millions
of dollars. There is now some hope. So, what
has Mark done? Well, he has given tremendous
performance. He is not walking but he is a very
active and vital person. He has learned which
domains he can succeed in. One of the domains
is outreach, another is public speaking, and
he has created a very positive environment for
other victims of paralysis. Every year when
I go to the Miami Project Dinner, I do so very
proudly. This guy is performing. So when I talk
about human performance, it is not always musculoskeletal
motion, it means movement forward. So we can
say, "OK, we have lost this, but what can
we gain given what we have? In spite of it all,
what can we accomplish"? That is how people
move toward goals. As my dad would say, "When
God closes one door, another one opens."
Patients must buy into that. When they do, they
start to grow and perform again.
JSV: The American Academy
of Experts in Traumatic Stress is truly a multidisciplinary
association comprised of over 100 different
specialties. What do you see as an advantage
of including orthopedists and oncologists as
well as police chiefs and other emergency services
personnel under the same umbrella as psychologists,
psychiatrists, dentists, etc.?
SJO: Again, we are all there
to assist people's performance. Everyone should
be part of that team. We are there to motivate
patients and help them--and the Academy may
be a vehicle to facilitate that goal.
JSV: What do you find helps
you relax after an especially difficult experience
with a patient or a hard day at the hospital
and/or clinic?
SJO: I like to hug my children
and my wife. I am the luckiest guy in terms
of having the most supportive wife in the world.
I never have to look back and worry because
my wife knows that I love her and, as soon as
I can, I will be home. So she doesn't put pressure
on me that way. We don't have as much quantity
of time but we have great quality time. I always
say that whenever I am home, it is like being
at F.A.O. Schwartz because I just love being
home. My greatest outlet is my family. I also
enjoy playing golf which is a great source of
relaxation for me because no one can find me
for four hours. The ability not to be found
for a few hours is something I cherish (laughs).
Other than that, I really don't have a lot of
time for many other things.
JSV: With technology changing
so rapidly, where do you see this area of medicine
going in the next five or so years?
SJO: I think we will be looking
at great strides at the cellular level in terms
of reducing human inflammation and physical
trauma. We are going to find ways to modulate
the body's response to injury. For example,
let's say you sprain your ankle and it blows
up like a grapefruit. Well, hopefully, in five
to ten years, we will be able to get the appropriate
response to affect healing but you don't get
a magnified response that creates the four to
six weeks of disability. Today, we may get massive
swelling, but hopefully, in the future, we will
learn some of the cellular clues to control
swelling, inflammation, and ultimately, reduce
pain.
JSV: I understand that you
are listed in the "Best Doctors" Guide.
How does it feel to be selected to be listed
in this prestigious resource?
SJO: I have been fortunate
enough to be included in some of those things.
I don't know how they are compiled. I have been
fortunate enough to have had great training
and a great mentor. I work very hard at trying
to be the best that I can be. I feel fortunate
to be considered in a category with the better
doctors. That doesn't mean that I am the smartest,
but I listen to my patients and ask a lot of
questions. We do a lot of research. I take pride
in saying that I think that I deserve to be
in that category. It feels good, but I am tired
(laughs).
©1997 by
The American Academy of Experts in Traumatic
Stress, Inc. |
