Trauma Response Profile

Stephen J. O'Brien, M.D.
Orthopedic Surgeon

Joseph S. Volpe, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Director, Professional Development

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.