| 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. |
