On a beautiful late-summer day in September 2015, Shawn Dollar was riding a wave at a remote break on the California coast when he fell and hit his head on a rock beneath the water. The impact broke his neck in four places and caused a massive concussion. Dollar once held the world record for the largest wave ever paddled into, and he's been in plenty of terrifying situations in the ocean, but he had never experienced anything quite like this. Despite blinding pain, not being able to move his head, and total disorientation, Dollar was forced to summon whatever strength he could to get back to shore without drowning in a maelstrom of rocks and whitewater along the wave-beaten cliffs. Once on land, he navigated a tortuous hike to get back to the road, where a friend rushed him to the hospital.
After being treated for his neck injuries, Dollar could only wait for his bones and muscles to heal while he tried to gradually increase his mobility. For months, he wore a neck brace to aid his recovery while his vertebrae stitched themselves back together and his strength returned. Finally, in December of that year, doctors said he was free to remove the brace and to slowly resume his normal activities. Dollar figured that the worst was over, as did his friends and family, and assumed he'd soon resume his regular life as a dedicated wave chaser.
He was wrong. The hard part was just beginning.
By Christmas, Dollar's neck had healed, but he was plagued by near-constant headaches, wracked by intense mood swings, and suffering from terrible depression. "As soon as the neck brace came off, everybody thought I was back," Dollar explains. "But I could feel my life falling apart. I didn't feel like I was being a good husband or a good father. I couldn't do basic math, my balance was way off, and I was starting to have suicidal thoughts."
"It became worrisome when months went by and Shawn hadn't improved," Dollar's wife, Jenn, remembers. "He had trouble with basic skills that we take for granted in everyday life—things that you may not even think twice about, like matching socks, trying to pick out a product on a shelf, or constructing an email. He had trouble with recall. There were memories that had gone missing, experiences that had fallen through the cracks."
Dollar first blamed his unstable mental state on the opioid pain medication he'd been taking for months. But when symptoms persisted after his dosage was reduced, Dollar began to suspect that the pain meds weren't the problem. The lingering confusion, depression, and occasional bursts of anger were hallmarks of a serious concussion. The standard medical treatment for concussions basically amounts to just waiting it out, but since that didn't seem to be helping, Dollar began seeking out alternative opinions and therapies.
Dollar consulted a brain-trauma specialist who agreed to perform a SPECT scan, a controversial imaging method that uses gamma rays to show how blood flows to the brain and, at least in theory, can reveal potential areas of trauma. The specialist and Dollar were baffled at what they found.
"The doctor looked at the scan and asked me if I'd played football in high school or college," says Dollar. "He said my brain looked like I'd been playing football my whole life. I had evidence of concussions on top of concussions."
The thing is, Dollar hadn't been a football player. Wondering why his scan might be displaying evidence of repeated brain trauma, Dollar considered his life as a big-wave surfer. "I'd taken some bad wipeouts at Mavericks and come up feeling dizzy, but I always got better," he says. Back in May 2016, when it was reported that BMX star Dave Mirra—who committed suicide at age 41 after battling the effects of numerous head injuries—had developed the debilitating brain disease normally associated with football players, called chronic traumatic encephalopathy (CTE), Dollar wondered if the same thing could be happening to him.
Concerns surrounding CTE and the complications an athlete can experience after suffering a concussion are no longer exclusive to football, lacrosse, hockey, and other contact sports. More recently, influenced in part by cases like Mirra's, the action-sports industry has begun to take stock of the nasty effects repeated shocks to the head can cause, whether from slamming onto a halfpipe, tumbling down a ski slope, or cracking a skull while surfing. A 2015 study published in the Orthopaedic Journal of Sports Medicine sifted through a decade's worth of data generated by emergency-room visits in the U.S. and found that concussion diagnoses are on the rise in sports like surfing, skating, skiing, and mountain biking.
Over 3,000 surfing-related concussions were reported in the study, but those figures are almost certainly low, since many people who suffer a concussion while surfing never go to an ER. Like me, for example. I once surfaced underneath my quickly falling longboard, which I'd kicked away in a stiff offshore wind, and it cracked nearly in half when it landed on my head. I emerged from the water stumbling and dizzy, then spent the rest of the afternoon huddled in my girlfriend's bedroom with the lights off, vomiting and suffering through the worst headache I've ever experienced. But my injury wasn't part of the above study since I (foolishly) toughed it out and didn't see a doctor, and there are likely many more surfers who've suffered concussions than what's being reported.
“He said my brain looked like I'd been playing football my whole life,” Dollar said. “I had evidence of concussions on top of concussions.” The thing is, Dollar hadn’t been a football player.
In 2011, Harley Taich, a promising junior surfing competitor from La Jolla, California, struck her head on a shallow sandbar while surfing a contest near Malibu. Taich came up coughing sand and water, and she collapsed as lifeguards helped her up the beach. She was later diagnosed with a grade-three concussion, the most severe form of the injury. Taich's recovery has been slow and terribly frustrating, the result of "post-concussion syndrome," a difficult-to-treat set of symptoms that can linger for years after the initial jolt of brain trauma.
"I saw eight different neurologists who all had different opinions about how to treat me," Taich explains. "Over the course of three years I've taken seven different medications to prevent migraines. After a few months, every medication I was prescribed would stop working and my headaches came back stronger."
Taich stubbornly continued surfing while her symptoms were still present, something she now considers to have been a mistake: "Going out in the water caused me to suffer small micro-concussions any time my head hit the water or I got tumbled. Even duck-diving was enough to rattle my brain and bring on my symptoms that put me back on bed rest for months. By paddling out as soon as I felt able, I never allowed my brain to heal, which is why I believe it took me close to four years to recover."
Taich has finally healed to the point where she feels comfortable surfing again and is no longer suffering debilitating symptoms from her concussion. "For now, I don't go out if it is super crowded or if the waves are too hollow and powerful. I stay away from the power pockets of waves. My goal is to keep from slapping my head on the water's surface. Every time I surf, I know how susceptible I am to getting another concussion. However, now that my symptoms have subsided, I'm not letting this fear hold me back from doing what I love most in life."
Considering the shallow reefs and sandbars that most of the world's best waves break over, it's surprising there aren't more well-known cases of severe head trauma in surfing. Jesse Billauer, the face of the Life Rolls On foundation, is probably the best-known victim of surfing-related head trauma. He was rendered quadriplegic after hitting his head and damaging his spinal cord surfing Zuma Beach, near Malibu. More recently, Owen Wright, who was ranked fifth on the World Tour at the time, suffered a concussion in 2015 while paddling out at Pipeline and being driven into the reef. Wright has only recently resumed surfing and it's still unclear whether he'll ever recover to the point of being able to compete.
Believe it or not, there's actually something called The Journal of the Surfer's Medical Association, edited by avid surfer and professor of emergency medicine at Brown University Dr. Andrew Nathanson. When asked about concussions in surfing, Nathanson said, "Thirty-seven percent of all injuries suffered while surfing are head and neck injuries," citing his own study from a decade ago that looked into the prevalence of brain trauma in surfers. His study showed that 8 percent of all head injuries in surfing result in concussions. "But overall, surfing is relatively safe," says Nathanson. "When you fall, you're typically landing in something that's cushioned: water."
With most surfing-related head injuries, however, the water itself is not the problem. Dr. Michael McDermott, a neurosurgeon at UC San Francisco, spoke to me recently about two adolescent surfers who had arrived at a hospital after suffering severe head injuries from being struck by their boards. Both later died from their injuries, which prompted McDermott to design a surf helmet that he hopes will someday gain traction in the surf-gear marketplace.
His helmet prototype is designed to protect areas of the skull that the few surf helmets for sale today often leave exposed. But after reaching out to gear manufacturers and talking with surf-retail experts, he's learning that his hope of getting more surfers wearing helmets may be a non-starter. "I think many surfers don't wear helmets because they just don't have an awareness of head and neck injuries," McDermott says.
McDermott is quick to point out that while helmets can ward off skull fractures, they don't offer any real protection against concussions. It's the brain rattling against the sides of the skull when the head jerks to a stop during a collision that causes a concussion; no helmet can slow the brain's movement in that situation. When I asked McDermott whether or not he thought big-wave surfers like Dollar were in more danger of concussions than us workaday surfers, he said, "It doesn't really matter if you're just surfing a regular wave. If the accelerating and decelerating forces are significant enough, then sure, that could cause a concussion."
Advanced helmets aren't the only preventative measure that researchers are exploring in search of new ways to prevent brain trauma in athletes. An M.D. named David Smith has spent the past few years studying woodpeckers, of all things, to figure out how they avoid concussions despite slamming their heads into trees thousands of times per day.
Turns out, woodpeckers have a bizarrely long tongue that they move with a specialized muscle that sits near their jugular vein. Smith theorizes that the birds are able to fill their skull with extra blood by constricting their jugular with their tongue muscle, and that the extra blood acts as a cushion within the skull. And Smith thinks it's not only woodpeckers performing little tricks like this. He argues that lots of animals that regularly bash their heads into things, including bighorn rams as well as seagoing birds that dive headfirst after baitfish, are able to manipulate how much blood they have in the brain either physically, like the woodpecker, or by deliberately increasing the carbon dioxide in their blood, which sends blood to the brain in an attempt to flood it with oxygen.
In experiments with high school football players who wore a collar that gently restricted blood flow away from the brain, Smith was able to show that as little as two extra tablespoons of blood in the brain appeared to lessen the amount of potential brain damage that the players experienced compared to those who didn't wear the collar. "I really feared for the future of football," Smith told the science magazine Nautilus earlier this year. "I actually don't anymore. I think we can prevent CTE."
Smith's work is still in the exploratory phase, but perhaps in years to come all athletes—including surfers and other action-sports athletes—will be filling their brain with more blood or futzing with blood chemistry to ward off trauma.
After months of recurring headaches and spiraling deeper into depression, Dollar began looking for alternative treatments to deal with his post-concussion syndrome. His search eventually led him to hyperbaric therapy, a treatment that uses changes in blood chemistry not to prevent concussions, but to facilitate healing. The treatment requires patients to spend time in a pressurized, oxygen-enriched atmosphere that forces extra oxygen into the bloodstream. This treatment, Dollar believes, finally began to pull him out of the darkness he'd dealt with since his injury.
The first thing I noticed when I walked into a Bay Area hyperbaric clinic to meet with one of Dollar's doctors was a row of footballs signed by various members of the San Francisco 49ers and Oakland Raiders. Football players have recently begun flocking to hyperbaric chambers hoping to ward off the damaging effects of butting heads thousands of times in their careers, and many local players left footballs covered in exuberant notes of thanks written in gold Sharpie for the clinic staff. I looked around for a signed Mavericks gun from Dollar, but so far, it's a football-dominated clinic.
Considering the shallow reefs and sandbars that most of the world's best waves break over, it's surprising there aren't more well-known cases of severe head trauma in surfing.
Dr. Scott Sherr, an internist who also specializes in hyperbaric therapy, met me at the clinic to show me how it all works. Sherr, a bespectacled young doctor, talked quickly and with lots of hand waving as he walked me through the facility and showed off their machines. The older hyperbaric chambers looked like tiny submarines—tubes of iron with thick-glass portholes and analog dials and readouts everywhere. The newer machines were Plexiglas tubes with TV screens and computerized controls.
Sherr walked me through the process: A hyperbaric patient simply lies in a chamber; while oxygen-rich air is pumped into the tube, the pressure is gradually increased to whatever level is deemed necessary by the doctor. Under pressure, you can take in more oxygen than at normal air-pressure levels, so the oxygen concentration in your blood rapidly increases. The saturated oxygen level is thought to facilitate healing in all areas of the body by increasing the amount and activity of white blood cells and by helping to speed the formation of blood vessels and nerve activity in areas that have experienced tissue damage.
"It's simple," Sherr told me. "A concussion is a wound in the brain that has to be healed, and hyperbaric therapy is advanced wound-healing technology." Dollar's treatment plan was dozens of sessions, or "dives," in the chamber, each of which lasts somewhere around an hour at about 1.5 atmospheres of pressure. In theory, every single one of these treatments was not only saturating Dollar's blood with extra tissue-generating oxygen, but they were also spurring Dollar's brain to grow more blood vessels, bringing more oxygen-rich blood to the parts of his brain that needed it the most.
Dollar had his first hyperbaric treatment in early January 2016, about four months after his injury. "I felt significantly better after the first treatment," Dollar told me. Sherr said that this experience is common. "Somebody without a brain injury might only experience a faint sense of mental clarity after hyperbaric treatment," Sherr explained. "But somebody who's been dealing with concussion symptoms can feel immediately better because their brain is receiving more oxygen."
While hyperbaric therapy has long been used for things like decompression sickness, gas poisoning, embolisms, and treatment of persistent infections, its usefulness in treating brain trauma is less understood and not something on which doctors agree. Neither Nathanson nor McDermott think there is any evidence that suggests hyperbaric therapy is a suitable treatment for concussions. The FDA lists "brain injury" among the conditions that hyperbaric therapy has not been proven to help treat.
The U.S. Department of Veterans Affairs conducted its own hyperbaric-therapy experiments with troops who've suffered brain trauma and they, too, came to the conclusion that the treatment can't be proven effective. But that doesn't keep many patients and their loved ones from touting the benefits of the alternative therapy.
"I truly believe that hyperbaric is what brought him back," says Jenn. "It came at a time when we were both scared and beginning to lose hope. We were not seeing improvements in his concussion symptoms on the timeline that his doctors had told us to expect. But after going to four or five hyperbaric sessions, it seemed like he was beginning to come back to his normal self again. He was able to think clearer, focus better, and feel calmer. He was able to function again."
In the weeks that have passed since I first started talking with Dollar about his recovery, his condition has improved. He's had 70 hyperbaric-therapy treatments at this point and he reports that he's feeling "70 to 80 percent better." Dollar has also begun another alternative treatment method called neurofeedback, which involves teaching a patient to control the brain's electrical impulses. "I felt like parts of my brain were not being used, and it was frustrating," says Dollar. "Those areas are now waking up, and treatment is exhausting, but I can feel myself pushing into 80 to 90 percent recovery. I'm seeing the light at the end of the tunnel now."
Dollar resumed surfing months after his initial injury, and his performance level is steadily increasing. But his days of throwing himself over the ledge at spots like Mavericks are largely over. "Even before the injury, I was certainly aware of the risks of things like concussions from riding big waves, and I was preparing myself to not surf Mavericks anymore," he says. Every doctor I spoke with was adamant that when a person has suffered a concussion as severe as Dollar's, it doesn't take much brain trauma to bring about recurrent symptoms.
His approach to returning to the water has been similar to Taich's: start slow, take it easy, and avoid movements that jostle the brain. But there is no way to completely remove the risk of re-injury, even in the most innocuous conditions. After all, the wipeout that changed Dollar's life wasn't at one of the terrifying hell waves he's famous for charging. It was at a break where many surfers would feel comfortable paddling out, and perhaps that is what's most concerning.
"It's crazy how action sports are starting to pay attention to this now," Dollar says. "Usually these athletes are so counterculture that they wouldn't care. Many still won't, but I'm glad that the discussions are happening."