When it was finally his turn, Mark MacDonald '08 strode to the front of the class knowing exactly what to do. He wrote his name on the blackboard and explained that his friends call him "Big Mac" because of his 6-foot-9 frame.
But then MacDonald paused, and the Lyman Hall basement started to feel a lot like the Pizzitola Center a few days earlier. There were the eyes of his peers, fixed squarely on him and anticipating his next move, but there was also confusion, dizziness and a sudden loss of memory.
MacDonald stood silently for a few seconds as the other members of TSDA 0220: "Persuasive Communication" looked on. The usually articulate center for the basketball team says he didn't just forget what he was going to say next, he forgot how to say it altogether.
So instead of continuing his introductory speech and talking about himself, he talked about Saturday, the game against Yale and the head-on collision with teammate Chris Skrelja '09 that sent MacDonald to the floor with a bloody nose and a grade-three concussion.
An academic injury
Adjunct Lecturer in Theatre, Speech and Dance Pamela Howell remembers that moment in Lyman 007 well. As a section leader for "Persuasive Communication," she assigned students to give two-minute speeches introducing themselves. She says that after MacDonald explained his nickname, he appeared to lose his train of thought.
"He didn't seem to make the transition into what he was going to talk about next," Howell says. "He kind of just stared off into space for a few seconds."
Though he regained his composure, MacDonald says his inability to concentrate hampered him academically for the week after the Jan. 26 injury.
"I was feeling tired, my thoughts were scrambled and I would get nauseous when I focused on the teacher," MacDonald says. "I just wasn't myself."
Friend and classmate Kim Bundick '10 says she noticed something different about MacDonald when they sat together in a sociology class.
"You could tell that he wasn't OK," says Bundick. "He wasn't really taking notes. He was just kind of staring at the professor."
MacDonald was fortunate enough to have his professors send him lecture notes and excuse his absences that week. But as Rob Cotter '06 learned his senior year, a strong support system isn't always enough.
It was April 2006 when Cotter, a defenseman for the lacrosse team, was running up toward the center of the field. A teammate then launched a pass a few feet behind him.
"I had to turn my head and body to make the play," Cotter says. "Before I could even look forward I just got trucked by some man-beast from Ohio State."
Cotter says he blacked out for a second but got back to his feet before returning to the sidelines. He eventually left the game. Though he was relatively symptom-free after a few days, he was pulled out of a game against the University of Notre Dame when his trainers realized he wasn't playing like himself. The physical exertion caused Cotter's condition to regress sharply.
Though on the sidelines for over a month, Cotter was expected to attend class like any normal student. But he quickly learned that his injury was not confined to the field, experiencing sensitivity to light and what he says felt like "a constant headache."
"I slept a lot and did not go to most of my classes," Cotter says. "It affected me, physically and psychologically. I was handicapped."
A complicated injury
Clinical Assistant Professor of Medicine Razib Khaund has seen his share of athletes with concussions like MacDonald's and Cotter's, both as a sports medicine specialist at Providence-area clinic University Orthopedics and as on-site physician at the 1996 Summer Olympics in Atlanta. But even he is quick to admit that little is known about the physiology of concussions.
"Advanced as we are in medicine, we are still quite limited in our overall management of concussions," Khaund says. "Only just recently has a consensus definition been reached of what a concussion even is."
But what doctors are well acquainted with, Khaund says, is the danger associated with them: symptoms of concussions range from irregular sleep and poor appetite to visual problems and cognitive dysfunction. Yet despite the severity of the condition, Khaund says people are often too careless in their identification and treatment of concussions.
"A concussion is literally a brain bruise," he says. "When you think about how we manage other bruises, we're very cavalier."
But Khaund says the biggest danger of a concussion is not the concussion itself, but the increased vulnerability to further damage - what Khaund calls "second-impact syndrome."
"After one concussion, the follow-up needed to cause a recurrent concussion is less," Khaund says. "The first insult primes your head, and a relatively innocuous impact the second time around causes a cascade of serious effects."
MacDonald suffered one serious concussion before his most recent, and Cotter got a second concussion a year after the Ohio State game.
Russ Fiore, Brown's head athletic trainer, says he and his training team are as careful as possible to guard against recurrent concussions. From the moment athletes are hit to the moment they step back onto the court or field, trainers watch them carefully.
"We start the assessment right on the sidelines," Fiore says. "If we suspect anything, we take you out of the game."
If an athlete takes a hard hit during a game, athletic trainers use a test called the Standardized Assessment of Concussion to quickly examine the player on site. Athletes are asked elementary questions about the current date and perform more complicated tasks such as remembering lists of words or reciting a string of digits backwards. They also do basic exercises like push-ups and sit-ups, as symptoms often reveal themselves during physical exertion.
Fiore says athletes suspected of more serious injuries are monitored physically and mentally over the following hours and days. They undergo further diagnostic tests at Health Services or even a hospital emergency room, where MacDonald spent seven hours the Monday after his injury. In the most serious cases, athletes must be free of symptoms for two weeks before returning to their sport.
But Khaund says even rigorous monitoring may not be enough to identify a concussion, because of the natures of both the injury and the injured.
"How many of those kids that want to impress the varsity coaches come out and take a hit, but don't want to tell the doctor or coach for fear of looking weak?" Khaund says. "Then they get hit again and get second-impact syndrome."
Cotter attributes the worsening of his condition to this sort of feeling. After the hit that caused his concussion, he ignored his minor symptoms and told the trainers he was ready to play.
"I wasn't being perfectly honest with the trainer. I told her I felt 100 percent when I didn't," Cotter says. "I was also trying to convince myself that I did not have a concussion." He adds that he might have missed only one week had he rested, "but instead I was out for six."
Fiore says false reports are always on the back of his mind, so he and the other trainers give stern speeches to every athletic team before the season begins.
"Don't lie to me," he says. "If you have a concussion, this is your brain, not your ankle."
MacDonald says at first he experienced a similar desire to play through the condition, but soon realized he couldn't ignore his injury.
"It's the biggest game of the season so far, and I'm a senior, a captain," he says. "But then I saw it was a little bit more dire than I first realized."
Fiore says he has one last line of defense against false reports. Two years ago, the athletic department began requiring all athletes to complete a cognitive function test called ImPACT - Immediate Post-concussive Assessment and Cognitive Testing - at the beginning of the year. In order for athletes with potential concussions to return to their sport, they must score as well as they did at the beginning of the year on ImPACT, which tests cognitive abilities from reaction time to higher-order reasoning.
"An athlete can lie to you," Fiore says, "but the one thing they can't lie on is the ImPACT test. That's why I like that test."
Fiore also stresses the importance of knowing each athlete and his or her particular behaviors personally so he can tell if something is amiss.
"Each of our athletic trainers (has) a close relationship with our athletes," Fiore says. "If I ask, 'How are you doing?' and I get a blank stare from someone who normally doesn't give me a blank stare, then I suspect something."
A social injury
Much as they would like to, Fiore and Khaund cannot treat concussions - the most common prescription is a healthy dose of rest. In time, Khaund says, patients recover on their own. But the meantime can be stressful for collegiate athletes in ways that have no relation to school or sport.
Cotter recalls his injury changing all aspects of his lifestyle - athletic, academic and social.
"I didn't watch TV without my sunglasses on for a month," he says. "You wouldn't believe how it affects your social life."
Cotter says one of the harshest symptoms of his concussion was a social awkwardness that accompanied him wherever he went.
"It's something that not too many people around you understand," he says. "You don't walk around with a sign up saying, 'I'm concussed.'"
Back in Lyman Hall, Howell says that an injury - especially one as private as a concussion - could intensify the already-demanding pressures of Brown's academic and social environment.
"I think they affect academics not only in terms of material retained, but there is a very real concern that any injury makes you feel very self-conscious, especially within the academic milieu of Brown. You worry you're going to appear dumber than everyone else," she says. "Many injuries are visual - someone's got a cast, someone's got an ice pack - and we have a certain amount of sympathy. But when you have an injury like a concussion, and it isn't necessarily explained to everyone, I think that itself becomes an embarrassment and a frustration."
