BehindTheMedspeak: Is Yankee catcher Jorge Posada being played for a fool by his doctors?

I read with interest a story by Jack Curry in yesterday's New York Times Sports section about Yankee catcher Jorge Posada's efforts to make sure he doesn't acquire brain damage from being hammered by dozens of foul tips off his mask along with the occasional pummeling when he blocks home on a play at the plate.

Long story short: Posada not only gets a CT scan of his head after each season ends, he also routinely asks for them during the season as he deems necessary — most recently last Saturday night following a full-speed collision with 240-pound Boston Red Sox runner Eric Hinske on a play at the plate (watch it above).

Here's the Times article, following which we'll go deeper into the subject.

Even During Season, Precautions for Posada

After the last three seasons have ended, Jorge Posada of the Yankees has scheduled an appointment to have a CT scan. As a catcher, who absorbs dozens of foul tips off his mask and who can get pummeled when he tries to block the plate, Posada wants to make sure he has not incurred brain damage.

Posada also requested a scan Saturday night after Eric Hinske of the Red Sox crashed into him at home as Posada tagged him out. The scan, which detects certain brain injuries but not concussions, was negative. Still, it is significant that the demands of Posada’s position have caused him to make the scan part of his off-season routine and, if necessary, his in-season routine.

The link between concussions and serious brain damage among some former N.F.L. players has become more pronounced, but baseball players, particularly catchers, are also at risk. Posada estimates that he has had three or four concussions in his career.

“Sometimes, you get it and you don’t even know you had it,” he said. “You play through the game.”

That play-with-pain mentality permeates locker rooms and clubhouses and could cause some dazed players to put themselves in jeopardy. Posada said that he had a “normal headache” after Hinske lowered his shoulder, raised his forearm and thrust his 240-pound body into him during Boston’s 10-1 victory Saturday. Still, Posada, who blocked the plate, called Hinske’s play clean.

“He’s got nowhere to go,” Posada said.

Although Posada’s eyes were bloodshot, he said that he slept well on Saturday night and that he was ready to catch Sunday night.

But Manager Joe Torre said he wanted “to be safe,” so he used Posada at designated hitter and let José Molina catch Roger Clemens. (Posada went 0 for 4.) Molina spent part of the pregame being advised by Posada about the merits of getting CT scans.

Torre, who started his career as a catcher, said he was rattled by foul tips and experienced collisions but never had a concussion diagnosed. He recalled how he was once clipped on the side of the head with a bat and joked how tests “revealed nothing” in his head.

But Torre turned serious when he discussed Posada’s decision to have off-season scans.

“I never thought about it until the football situation came up and they talked about the cumulative effect of so many” concussions, Torre said. “It’s frightening.”

Catcher Mike Matheny retired from the San Francisco Giants after last season because of a series of concussions. When Matheny was placed on the 15-day disabled list, he said he did not think he would need all 15 days to recover, but he had postconcussion syndrome and never returned.

Posada nodded when Matheny’s name was mentioned Sunday. But Posada, who entered Sunday leading American League catchers in games played (127) and innings (1,029 1/3), insisted that he could not be effective if he was worried about the possibility of injury.

“You can’t think about the negative and stuff that could happen,” Posada said. “You just got to keep on hoping that everything is going to be fine and you can keep playing the game.”

Two batters after Hinske collided with Posada, Posada reacted slowly on another play at the plate. Posada said his tag was high because he expected Jacoby Ellsbury to barrel into him, too. Posada did not directly answer whether he felt woozy.

Tony Peña, the Yankees’ first-base coach, caught for 18 years and never had what he called “a major concussion.” But Peña said he blacked out several times after being hit by foul tips.

Peña, whose youngest son, Francisco, is a minor league catcher with the Mets, said he had noticed that fewer young players were rushing to put on the mask.

“You need to understand you’re going to get hit and you’re going to have to play with pain,” Peña said. “It’s one of the reasons kids don’t want to play the position.”

Like Posada, Peña said he never obsessed about concussions or head injuries once he crouched behind the plate.

“We play that position because we love it,” Peña said. “You never think about getting hurt.”

Derek Jeter, Posada’s teammate and close friend, said Posada had a “hard head” and would be fine. Posada did not laugh about Jeter’s comment. Instead, he noted this remark from Jeter: “He said he couldn’t do what I’m doing.”

As a fellow catcher who has been in Posada’s shin guards, Peña said he feels for Posada whenever he gets bowled over. But Peña smiled and talked about how satisfying it was to see a catcher take a hit and hold onto the ball, as Posada did.

“When the umpire raises his arm and says the guy is out, you’re proud,” Peña said. “Your catcher did what he was supposed to do.”

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"The scan, which detects certain brain injuries but not concussions" — wait a minute.

If the writer knows this, you'd assume Posada does too — right?

Maybe not.

Maybe the Yankee team doctors encourage him to get a CT scan "just to be sure."

Bad advice — no one needs the extra radiation.

In fact, the increased risk of a brain tumor from the cumulative exposure to all those CT scan-generated x-rays is probably greater than or equal to the chance they'll show anything useful that hasn't already been diagnosed as a result of Posada's physical signs and symptoms.

The physical signs and symptoms of concussion remain the gold standard for diagnosis, just as they were back in the dark ages when I went to med school and rotated through third year neurology.

A negative CT scan doesn't necessarily mean everything's OK upstairs.

Consider, for example, the following abstract of a 2006 paper on the subject published in the journal Academic Emergency Medicine.

Bench to bedside: evidence for brain injury after concussion — looking beyond the computed tomography scan.

The emergency management of cerebral concussion typically centers on the decision to perform a head computed tomography (CT) scan, which only rarely detects hemorrhagic lesions requiring neurosurgery. The absence of hemorrhage on CT scan often is equated with a lack of brain injury. However, observational studies revealing poor long-term cognitive outcome after concussion suggest that brain injury may be present despite a normal CT scan. To explore this idea further, the authors reviewed the evidence for objective neurologic injury in humans after concussion, with particular emphasis on those with a normal brain CT. This evidence comes from studies involving brain tissue pathology, CT scanning, magnetic resonance image (MRI) scanning, serum biomarkers, formal cognitive and balance tests, functional MRI, positron emission tomography, and single-photon emission computed tomography scanning. Each section is accompanied by technical information to help the reader understand what these tests are, not to endorse their use clinically. The authors discuss the strengths and weaknesses of the evidence in each case. These reports make a compelling case for the existence of concussion as a clinically relevant disease with demonstrable neurologic pathology. Areas for future emergency medicine research are suggested.

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Allow me to put the key finding from the above abstract in boldface: "Brain injury may be present despite a normal CT scan."

It's not that the CT scan is completely worthless as a diagnostic tool after head trauma (though it's still way overused).

Rather, it's that a normal CT scan will result in many cases in an individual who has in fact sustained a concussion being cleared as ready to return to their usual activity or sport.

Posada's just another victim of so-called "V.I.P. medicine" — where people who are famous, wealthy or otherwise noteworthy receive not the best but oftimes substandard care.

Regardless, that's one awesome play Posada made — can you believe he held onto the ball?