| 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. |
