The Ken Dryden rule: No hits to the head, no excuses
In his book Game Change, Ken Dryden explores hockey's shift into a high-injury sport and the roadblocks to on-the-rink reform. Read excerpts from the book below, along with a Globe and Mail series on the science and politics of concussions
'He is symptom-free and doing well. He is therefore clear to return to play'
In this excerpt, Dryden delves into the medical notes of three doctors who examined Steve Montador, who died in 2015 at age 35 after a lifetime on the ice. He also explores the personal journal of Montador himself, to tell the story of his final season.
Then the concussions came.
On Jan. 8, 2012, the Blackhawks played Detroit. When the game was over, Steve went to see Dr. Michael Terry, one of the Blackhawks' physicians. He had been hit in the face with a punch, he told Terry, and as Terry later recorded in his notes, had "a brief period where his consciousness was altered," where he "felt like he was a little hypoglycemic" and "a little bit hazy."
Terry put him through some tests and wrote: "[H]e was able to perform serial 7s. Three word recall was intact. His modification of SCAT [Standardization Concussion Assessment Tool] was otherwise normal although he was unable to do 3 number reverse recall and 4 number reverse recall without prompting. Otherwise normal neuro exam. Cranial nerves 2 through 12 are intact. His balance is normal. His affect was normal."
In his notes, Terry concluded: "A/P [Assessment and Plan]: concussion. We are going to put him through our protocol for return to play." On Steve's Fitness to Play Determination Form, which he signed, Terry wrote: "Disabled."
Two days later, Jan. 10, before the Blackhawks game against Columbus, Steve was given a neuropsychological examination by Dr. Elizabeth Pieroth under the NHL Concussion Program. Steve described his injury and symptoms to Pieroth, as he had done with Terry.
Pieroth later wrote in her report that: "The player was a poor historian regarding his concussive history. He stated his most recent concussion occurred February 2011 but he could not recall how he was injured. He denied loss of consciousness or retrograde/anterograde amnesia and experienced only headache and neck pain. Steve believes he missed 2–3 games and thinks this was due to neck pain."
Further, Pieroth reported, "In 2009 he was hit in a practice and missed 2 games but wasn't sure if he had actually suffered a concussion at that time. The player also reported that in September 2000 he received a blow to the head and was out of play for one week but does not recall what symptoms he experienced or how long [they] lasted." Pieroth checked Steve's recollections against those he had reported on his earlier NHL tests and found them "not entirely consistent." In addition, "Steve cannot state if these were all concussive injuries. He denied any other head injuries or significant medical history."
Pieroth went on, describing his present symptoms after the hit two days before. "Currently Steve did report trouble falling asleep and irritability but stated this was secondary to personal issues and not related to his concussions. He has also completed the Blackhawks' exertional protocol without eliciting any symptoms. Therefore he can be cleared to play in this evening's game with the team physician's approval."
Pieroth concluded her report: "Steve was also provided with education on concussive injuries and we discussed the current signs of multiple concussions. I explained to him that it is difficult to determine if he has demonstrated increased recovery time or increased vulnerability to concussive injuries given his poor recollection of his past injuries. However, given his report, the player does seem that he has recovered along expected lines from his previous concussions. Steve stated that he understood my concerns but is comfortable with assuming the risk associated with continued play at the professional level."
Steve's Fitness to Play Determination Form, again signed by Dr. Terry, reads: "Not disabled."
Steve played that night against Columbus.
Almost a month later, on Feb. 8, Adam Jahns of the Chicago Sun-Times reported that Steve had left the game the night before against Colorado in the second period, "and didn't return because of an upper-body injury. He underwent X-rays for his injury before the Hawks left the Pepsi Center. His injury isn't thought to be serious. 'He's doing OK today,' [Blackhawks coach Joel] Quenneville said. 'We'll see how he is [tomorrow].'"
The next day, Steve was put on the injured reserve list.
Nearly three weeks later, having seen Dr. Terry again and still feeling symptoms, Steve decided to seek another opinion. He went to see Dr. Jeffrey Kutcher at the Michigan NeuroSport Clinic at the University of Michigan hospital in Ann Arbor.
Kutcher, in his report, filled in some of the details between Steve's initial injury on Jan. 8, his examinations by Terry and Pieroth, and his injury against Colorado on Feb. 7. Kutcher noted that after his Jan. 8 injury, Steve played the next four games "without any symptoms or difficulties."
Then, he wrote: "On January 18th, he was struck in the head by an opponent's shoulder which caused a more significant constellation of symptoms. For the next 2 weeks, he felt forgetful, emotional, and 'out of it.' He was beginning to sleep poorly. He was having mild diffuse generalized head pain. Despite this, he continued to participate in hockey."
On Feb. 3, Steve was in a game when he was hit from behind causing a whiplash-type of movement. This resulted in perhaps a short duration of loss of consciousness. He continued to play, however; and on Feb. 7, while playing a game at Colorado, he was involved in a more subtle hit, but one that caused an immediate flash of a green fence in his vision. He played the rest of the period, but then removed himself from participation.
A "green fence" is one of a variety of visual images, which appear in different colours, that concussed people recall seeing at the time of impact.
Steve had been injured first on Jan. 8, then again 10 days later on Jan. 18, then two weeks after that on Feb. 3, then four days later, on Feb. 7. His meeting with Kutcher occurred 20 days after his last injury in Colorado. Kutcher described his symptoms that day:
"Currently he is continuing to experience focal pounding headaches that last anywhere from 5 min. to 2 hours. They occur sporadically, but also with minimal exertion. Symptoms at baseline have improved otherwise, but he still describes having problems with sleep, mood, and appetite. As he has improved, he has attempted to return to physical activity with two trials on a stationary bike. One was on February 23rd for 10 min. and when his heart rate got to approximately 120 he had a significant increase in head pain. He again tried this on the 24th with essentially the same results."
Kutcher also gave Steve a general examination, and described what he found as "unremarkable." He put him through additional tests while he was at rest, then after, 22 minutes of exertion on a stationary bike. The next day he gave him the same bike test, then some agility drills in the gym followed by drills on the ice. "He did very well tolerating exertional levels much higher than previously noted," and "without any significant increase in symptoms," Kutcher wrote.
He concluded: "I was encouraged today by his performance and the rather subtle symptoms that he expressed." Kutcher added a note of caution: "At this point, while I'm encouraged, I would like to be very careful moving forward," and he suggested "we progress along a very careful rehabilitation program that stresses both increased exertional levels as well as agility, movement, visuospatial tasks, and the cognitive aspects of playing hockey."
Kutcher added: "[W]e discussed the possibility of medications to help. He would like to forgo any medications at this time, but we will continue to monitor his symptoms and he may reconsider this in the future."
Steve returned to Chicago. On Feb. 29, he was examined by Dr. Terry. The doctor's dictation note was less encouraging: "[Steve] still is feeling foggy. He has not noticed a good deal of change but he has been exercising a bit. He says that he stops when he is symptomatic." Nine days later, Steve saw Terry again. The doctor's dictation note reads: "[Steve] says that he has been feeling better. Will have an occasional feeling of vertigo or dizziness. An occasional headache. He said that they are both very rare. Overall he said he otherwise feels essentially normal with no focal symptoms."
After Steve's initial injury on Jan. 8, his journal entries became more sketchy and sporadic. On March 14, he wrote:
- 1. Gratitude – health
- 2. Gratitude – game
- Remaining Empowered
- Concussion – stop the noise
Later the same day, he asked:
- What is this teaching me about being a competitor?
- keeping things simple
- how to handle reality
- accepting fallibilities …
- overcoming adversity
More often, he began a thought in his journal and didn't complete it. He wrote of his gratitude for the chance to play with "this unique club": "I'm good, it's fun, there's tough patches but that's OK. [My] capacity for survival is phenomenal. Pat self on back, it's OK. I bring a lot to the team. I know my being there boosts that environment."
A week later, on March 21, Steve saw Dr. Terry again and told him he was feeling better. Terry noticed no symptoms, and noted that Steve's modified Standardized Concussion Assessment Tool (SCAT) was "normal." Steve's Fitness to Play Determination Form, signed by Terry, read: "Not disabled." Four days later, on his dictation note, Terry affirms Steve's status: "He has been treated for a concussion. He presents today with no symptoms. He completed his exercise protocol and impact testing and passed both. He is symptom-free and doing well. He is therefore clear to return to play."
On March 27, 2012, 35 games after his initial injury, 23 games after his fourth injury against Colorado, Steve dressed against New Jersey. He played four minutes and 20 seconds. In the third period, playing on the wing, he crashed the Devils' net and got an "inadvertent elbow" to the head from defenceman Mark Fayne.
The next day, Steve's Fitness to Play Determination Form, signed by Dr. Terry, read: "Disabled."
Steve never played in the NHL again.
It never seemed it would happen this way. Steve's return to play was always a matter of time – time to allow things to settle, time to let the brain heal. A different doctor, a new treatment, a different understanding and approach to concussions, and to paraphrase what Steve had written in his journal, "Something's gonna happen to magically make me better."
He had always gotten better before. Athletes get better. You feel, you deal, it passes, you get on with it. That's how it had been with his back, his knee, his neck. That's how it had been with his head. Headaches, dizziness, fatigue, sensitivity to light – symptoms that felt like they were going to last forever always went away. No scars left behind, nothing he could see in the mirror, nothing anyone else could see even on MRIs, no indications that anything had happened.
It was only when he was asked by doctors about his medical history that he even remembered all those other hits to his head, that they might have been something. The time in minor peewee, that other time in junior. Those times in Calgary when he was trying to make the team, when he did a face plant on the ice and cut up his nose and cheek, when he got knocked silly by an elbow, when he got sucker-punched in a bar. The time in Florida when he ran into an opponent's helmet with his face and broke his nose again. Then, in Buffalo, another elbow, a stick, more cuts, another break to his nose.
In every instance the injury he thought he received was a break or a cut, not dizziness or headaches. It was the same earlier in the season when he slid into the boards with his face and fractured his zygomatic arch and temporarily lost his hearing. He'd had a brief loss of consciousness; but isn't that just what happens when you break your cheekbone? If he had a banged-up shoulder and a headache, which injury was he going to focus on? Players get hurt game by game; all his big head-hits, until that season, had happened months and years apart. He'd gotten better in between. He was always fine. He had a game to play.
Athletes have their own kind of relationship with pain. They play because they are so absorbed in playing that they don't notice injuries when they happen. The soldier who is shot keeps on going because the imperative to go on is so much more important than the imperative to fall. The explanation for such a miraculous act is purpose more than courage.
So players play. And players expect other players to play. Someone goes down in a hockey game and is helped off the ice. "He'll be back," the announcer says. "He's a hockey player."
'Is he big enough? Is he physical enough? Can he take it?'
In this excerpt, Dryden explores how quickly minor hockey evolves from a kids' game to one that emulates the pros.
[Jim] Donaldson coached Steve during the most pivotal minor hockey season for every kid – the year when body-checking is introduced (the age has changed over time, and varies depending on the province). There had been lots of body contact in the seasons before, of course, but it was incidental – two players going for the puck and bumping into each other – and (mostly) accidental. In Toronto, minor hockey tryouts are held in May for the next season, not long after the previous season has ended. When coaches select their team before that body-checking year, they have to ask themselves for the first time: Is he big enough? Is he physical enough? Can he take it? For those kids and their parents who get the good news, they spend the summer thinking about what's ahead, all of them excited, but many also fearful. Some kids mature earlier; some later. One of Donaldson's players made the team in May wearing size eight skates and started the season four months later in size elevens. Physical growth brings confidence and aggression to some kids, and gangly, mismatched body parts to others. And suddenly, on the ice, these kids are allowed to collide.
In that first checking year, players look like little bighorn rams running at each other, and they can't stop themselves from doing it. For weeks into the season and sometimes longer, the puck is almost forgotten. The kids have to prove – to their coaches, to their teammates, to their opponents, and to themselves – that they are tough enough to hit and to take a hit, in this game, next game, every game.
How a young man's brain can teach scientists so much about hockey's toll
In this excerpt, Dryden takes us into the search for chronic traumatic encephalopathy (CTE).
She sees so few brains of "young ones," as she puts it – those who are 40 years old or younger, but who during their lifetimes exhibited symptoms of those much older: memory loss, loss of emotional control, loss of cognitive function. [Dr. Lili-Naz] Hazrati is rarely shocked by what she sees, because she never anticipates what she will find. She is a scientist, and she must see only what is there. "The organ is what gives you the most information," she says. "You must let it tell the story." Still, a young brain like Steve [Montador]'s that looked so normal and healthy – but wasn't – was a surprise to her. "This was a young person who shouldn't be dead now," she says. His brain should not have been on the autopsy table in front of her, in that small, spare, surgically clean room.
As Hazrati puts it, brains like Steve's are "very precious," and extra care must be taken. Not because they are from well-known athletes, but because these athletes have died so young – and because the disease these brains contain is so little understood that every glimpse into them matters. They are precious because, for researchers to discover what they haven't yet been able to, they need lots of brains in order to gauge differences, uncover similarities and have new things to think about and new findings to share with other scientists. Researchers have examined brains affected by Alzheimer's, Parkinson's, ALS and other neurodegenerative diseases for decades. They still don't know the causes of these diseases, or how to cure them, but they have studied them enough to know there is a certain predictability to them. This is less so the case with CTE. It seems that the disease is related to blows to the head, but not limited to them. After all, even the most physically inactive among us have hit our heads hard many times in our lives. What is it about the brains of these athletes that are different?
Why helmets didn't protect players the way we thought they would
In this excerpt, Dryden explores the notion of equipment designed to protect a hockey player's head.
Equipment was becoming more protective. After all, why should a player feel the pain of the ice, the boards, the glass, a puck, a stick or an opponent's body if he didn't have to? Pain distracts and slows a player down. So why not play with abandon? With better equipment, why not hit with the same force with less pain, and hit more often; or with greater force but with the same pain? Why not do everything that is in you, with no compromise of performance for safety?
Head injuries, except for visible ones to the face, didn't seem much of a problem even at this time – and almost every player now wore a helmet. Some helmet skeptics had argued for decades that head protection made a player more, not less, vulnerable. Without a helmet, a player can sense danger even from behind; with a helmet, it's as if his radar is jammed. But most of the skeptics just didn't like helmets. Fans identify with their heroes and want to feel for them, but when everyone wears a helmet, everyone looks alike, they argued. Fans can't see that look of triumph or disappointment on a player's face. When Guy Lafleur started up ice with the puck, fans could see his hair flip up then stream out behind. They could feel his speed. With a helmet on, some of that excitement was gone.
The helmet would have much less of a protective effect than everyone imagined, a fact that wouldn't come to be known until recent years. Helmets lessen the risk of a fractured skull, but do almost nothing to prevent concussions. Hockey still remained a compromise between performance and safety – even if most believed that both were possible pursued to their fullest, and compromise was no longer necessary.
'Sometimes things happen that we don't understand'
In this excerpt, Dryden looks at how diagnosing concussions doesn't tell the whole story of the brain.
Four concussions in eighteen months tells us a lot. It is the writing that is unmissably on the wall. But it doesn't tell us everything because we don't know everything. Sometimes things happen that we don't understand. We have to allow for that. We have to believe that we can create our own destiny every bit as much as science creates our destiny for us. After all, the concussion tests only say "not now." They don't say "not ever."
Once [Ottawa Senator Clarke] MacArthur had started things in motion, once he kept on trying, kept on training, kept on showing up at the rink, once he had failed his baseline test but wouldn't go home, what was going to stop him? Once he kept feeling a little better, and a little better, it was clear the team needed him and he needed the team, and the playoffs were getting closer. Once that mountain of hope and need to play built and built, higher and higher, and the story got better and better, who was going to say no to him? Who was going to tell him he couldn't play? MacArthur, his wife, his parents, his teammates, his coaches, his GM, his owner, the doctors, the NHL's Department of Player Safety, Gary Bettman? That would be so unconscionably cruel. He just wanted to feel normal again, and as it was with Marc Savard, normal was to play.
In Game 2 of the second round of the playoffs, Ryan McDonagh of the Rangers struck MacArthur with a high, hard, but not shuddering check. He left the game with what Ottawa called an "upper body injury," what they and MacArthur later said was a pinched nerve in his neck, unrelated to the previous concussions he had suffered. Clarke MacArthur returned to the lineup for Game 3.
'The game has changed constantly. It is always changing'
In this excerpt, Dryden explores how the game has always evolved.
Rule-makers created high-sticking and elbowing penalties specifically to protect a player's head. Yet there was an exception to this. For the head to get this special treatment, it had to be up at the moment it was struck. If it were down, the hit was considered to be the player's own fault; the player was "fair game."
This thinking arose out of the pre-forward pass era. If a player has to advance the puck up the ice without passing, he has to stickhandle, which is easier to do if he looks down at the puck. If stickhandling is to his advantage, the checker should have some advantage of his own. So a hit to the head by a stick or an elbow wasn't allowed, but a hit to the head by a shoulder or a hip delivered with far greater force was not only okay, it was glorified, as long as the player's head was down. It was a "freebie." There is another category of hit to the head that is also penalized but accepted: a fist to the head. It's because it has never been seen as a hit to the head, but rather as fighting, which isn't possible without some fists to the head, and is acceptable, in fact essential, because hockey is a passionate game different from other passionate games, and an emotional release is necessary.
This is all very admirably consistent, but even if it wasn't, even if you wanted to make these changes, you can't. The game is the game and you can't change the game. It has been played this way for 100 years. The traditionalist "knows" this.
But it hasn't. The game has changed constantly. It is always changing. The traditionalist is blind. The game is much faster. A hit to the head from a shoulder moving at 35 kilometres an hour is a hit from a much different shoulder than 50 years ago. A hit to the head from the fist of a bigger, better-trained fighter is a hit from a much different fist. A hit to the head today is a much different hit.
'What happens if Canada's collective experience is no longer so collective?'
In this excerpt Dryden explores the notion that hockey is so much more than just a game.
A hockey life is a full family life. It takes a family's time, spends a family's money, monopolizes a family's priorities and emotional energy. It offers the kids an experience with other kids, with a team, with goals and dreams, ups and downs, that is never forgotten. For parents of earlier generations, the decision for their kids to play sports was easy. The rewards were not as great, the commitment required was much less – and besides, there wasn't much else for their kids to do. Now there were a lot of other things to do. There was a choice – other activities, that involved less team-time and more family-time, that were less dangerous. Give parents something to worry about and they will worry. They know their kids might get hurt doing whatever they are doing, and might get hurt more often in sports. But this was different. Head injuries carry such unknowns. A leg that limps is one thing; a brain that limps is another.
So why not play soccer, many parents thought. It's so healthy. The kids just run around, and all you need are shorts and a ball. Or basketball? Or skiing, as Paul Montador had hoped for his kids – something they could do as a family; spend their weekends doing together. Concussions gave parents looking for a way out, a way out. And beyond the tens of thousands of individual families suddenly presented with a choice – what did it all mean for the game itself? Who was going to play, and who wasn't? Hockey's first game was played eight years after Canada was born. It has been part of the way Canadians live since then. What happens if Canada's collective experience is no longer so collective?
Excerpted from Game Change: The Life and Death of Steve Montador, and the Future of Hockey. Copyright © 2017 Ken Dryden. Published by Signal, an imprint of McClelland & Stewart, a division of Penguin Random House Canada Limited. Reproduced by arrangement with the Publisher. All rights reserved.
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