They bring their rattled brains, and usually their parents, to him on a regular basis.
These young athletes, many of them hockey players, are in varying states of recovery from concussion, but prominent neurosurgeon Dr. Charles Tator knows that far too often there is only one recommendation he can make.
It's a line that should not be crossed again.
"When athletes come to see me and they've had several concussions and they haven't recovered, I have to tell them that you can never play again, never participate in contact sports ever again because you have used up your reserve and it's too dangerous to go back and put yourself at that risk," Tator says in his office at Toronto Western Hospital.
"They cry in my office, the parents cry and the parents argue: 'He looks OK to me. Why are you preventing him from playing again? He has to play again. The team needs him.'
"We do get that opposition from some parents. Or they'll fight right in the office. I feel sorry for the kids."
The dangers of second-impact syndrome or repeated concussions are non-negotiable for Tator, a spinal-cord and brain-injury expert who was one of the founders of ThinkFirst Canada, the national non-profit injury-prevention organization, in 1992.
He knows all too well that concussions aren't what they appear to be, because they rarely appear to be anything at all. There are no slings or casts, and X-rays, MRIs and CAT scans don't reveal them.
"It's hard for the concussed athlete to explain to people what they're feeling," Tator says. "They feel defensive about it. They feel they're letting the team down, that they're letting their parents down, that they're letting themselves down.
"The desire to play remains, but we have to go beyond that; we have to think about protecting them for the rest of their lives. There is life after hockey. We have to point that out -- that in order to participate in that life after hockey that they have to have full mental functioning."
Those who have not stopped in time, or who have suffered excessive damage in repeated incidents, are more susceptible to long-term behavioural changes or cognitive impairment.
"It's tragic when they never get back to their pre-injury personalities and abilities," Tator says. "Some end up as different people than they were before the concussion. There can be a lot of psychological damage as well as the physical damage, because they can become significantly depressed."
Tator's background in this area is extensive and his reputation is substantial. Yet some parents and patients -- as many as one-third, he says, noting some tracking statistics -- refuse to accept his diagnosis or advice.
Instead, those doubters go doctor-shopping, looking for someone less-informed who will tell them what they want to hear.
That's why ThinkFirst's mandate is so important, Tator says.
"It's one of our goals at ThinkFirst -- a concussion education and awareness committee to try to educate parents, players, leagues, coaches, trainers, but to educate doctors, too," he says. "Many of my colleagues who are not well-informed, who don't know how to diagnose or manage concussions, we need to reach as many of them as possible."
IN Canada, trauma is the leading cause of death in people under 44. And of those, deaths due to head injuries top the list.
Tator confronts the demons of those injuries every day -- in the lab with his research, in the operating room with his neurosurgical expertise and across the country with his message.
He determined long ago that the best time to tackle spinal-cord and brain injuries was before they happened.
ThinkFirst was a strategy borne of more than a decade of frustrating observation and treatment at Toronto's Sunnybrook Health Sciences Centre and the hospital's trauma centre, mainly of hockey players who had broken necks.
"It was the futility of current treatment that has made me so involved in prevention because we cannot restore tissue that has been lost," Tator says. "The only cure at the present time is prevention."
Statistics on broken necks in hockey mounted until about 1995, but have declined since. Tator says that from about 18 a year in Canada, the incidence is now about six annually "because of injury prevention strategies."
"I won't say we solved the problem with broken necks, but we've certainly made a dent in it," Tator says. "It's a significant decline."
The medical world's focus on spinal-cord issues in hockey was broadened about 10 years ago. Eliminating hitting from behind in hockey remains a priority, but an old condition was clearly on the rise.
"During this time, it became apparent that concussions were going the other way," Tator says. "I started seeing all these kids with concussions in the office that I never saw before. It was obvious to everybody seeing these kids that something had to be done about concussions.
"ThinkFirst got really interested in trying to do something about concussions in about 2000."
Another inspiration for Tator's commitment to improve safety was Toronto ophthalmologist Dr. Tom Pashby.
Pashby was an instrumental figure in lobbying Hockey Canada (then the CAHA) to make helmets and eventually face guards mandatory for minor hockey. Through his research on equipment and its standards, both those rules were in place by 1980, and by 2000, five years before his death at age 90, the number of hockey injuries resulting in blindness was less than five.
The number had been 10 times that in the 1970s.
Tator remains a director of the Dr. Tom Pashby Safety Fund, which supports programs designed to prevent catastrophic injuries as well as its own annual award in the sport safety field.
BLINDNESS and broken necks are way down in hockey, and equipment has come a long way from the Eaton's catalogue shin pads and cardboard helmets.
But what advances have been made in understanding and treating concussions?
1. A concussion is a brain injury.
"When I went to school, we never thought of a concussion as a brain injury, but now we know it is," Tator says. "We used to think of it as a chemical imbalance and people used to say 'ding,' or 'seeing stars,' or other things. But we know it's not a ding, it's a brain injury. It was an important step 20 years ago."
12. An evolving definition of what a concussion is. Tator was taught that it meant loss of consciousness. "Now we know that 95 per cent of concussions occur without being knocked out," he says. "Only one in 20 gets knocked out; the other 19 would have gone unrecognized. We are now able to better recognize concussion."
13. The dangers of repeated concussion. "We didn't fully appreciate in the past that the punch-drunk syndrome can happen to football, soccer and hockey players," Tator says. "We thought it only happened to boxers and we always knew that boxing caused damage to the brain."
14. Concussed? See a doctor. "We've only been saying that for 10 years; we never taught that before," Tator says.
15. The term "mild concussion." As useful as "mildly pregnant." You either are or aren't concussed.
RESEARCHERS and medical experts aren't sitting still.
In his laboratory, Tator is currently focused on trying to regrow nerves after spinal-cord injury.
"We're looking at stem cells as a means of replacing some of the damaged brain or spinal cord," he says. "We do transplantation and it does make a difference in rats, so there is hope that someday this might be applied to humans with brain injuries or spinal-cord injuries."
More specific to concussion, Tator, like many other experts in the field, are eager to dig deeper with the alarming findings from a Boston-based study that reveals the extent of damage in the brains of former football players, and even last summer, former NHL tough guy Reggie Fleming.
They produced a severe, long-term condition called chronic traumatic encephalopathy.
"We're just at the beginning of the research in being able to identify hockey players with this," Tator says. "These nerve cells with this gunk in them, and the cluster of them, you can't think when you've got that stuff in your brain. You lose your memory. We don't know: Does one concussion cause that?"
In an attempt to find answers, the Krembil Neuroscience Centre Concussion Project at the Toronto Western Hospital has been started.
Dr. Richard Wennburg, Tator and neuropathologist Lili Hazrati will open the program to "any hockey players who want to will their brains to us."
"We'd like to do the same thing as the group in the U.S. has done on football players," Tator says. "We would be in a position to do the examination and to try to do the correlation of how many concussions they had and what the clinical effects were of those concussions."