I've hollered, “GET HIM!” more times than I'd like to admit as my son charged toward someone else's son to knock the snot out of him on the gridiron. Football somehow has the ability to turn mostly rational adults, myself included, into screaming zealots. It transforms our sons, too, when they step onto the football field; mild-mannered 8-year-olds are suddenly little warriors fervently sacrificing their own bodies.
My son, Cole, first injured his head during one of his earliest practices in pads, before he mastered leading with his shoulder. He was overeager to test his new helmet and without abandon went full speed headfirst into his buddy: Nick of formidable frame and linebacker build. He didn't pop right up the way he usually does but laid there dazed. He finally reoriented himself enough to stand and remove his helmet, and he had a forehead hematoma to show for his first full-force tackling effort. Sadly, not only was he proud of himself, but the coaches praised his effort. “No more pretty boy, Cole. Now you're a football player.” I'm embarrassed to admit it, but I actually took a picture to memorialize his first football injury.
There has always been a proud machismo in toughing out injury. I succumb to it, too, as a mom. But I know as a doctor that most sporting injuries for boys occur in football, and I'm ever-cognizant of the risks. Even though the literature is wrought with confounding variables, I'm leery of the potential for chronic traumatic encephalopathy. I'm also mindful that concussion begets concussion; that is, one concussion in a season confers a three-time risk of a second concussion that season. While my sons battle on the field, battle rages within me between the “get 'em” football-mom and the protective doctor-mom.
How do we balance raising tough men and protecting them? We can let them do what they're passionate about if we teach them safety. Tackling education is a must, and we should be vigilant. When I'm on the sideline, I'm watching like a hawk when a player doesn't get up, and I am quick to react. The cautiously vigilant mindset of an emergency physician trained to exclude worst-case scenarios can be an effective balance for football field machismo.
Fortunately, the recent boom in publicity about concussions gives us more opportunity today than ever to promote cautious sideline vigilance. Coaches in our football association are now required to complete concussion training, and parents are given the option for preseason baseline neurocognitive testing. With increased public awareness, nobody should be using the old-school “He can see two fingers; he's OK” approach. Unfortunately, obstacles to safer practice remain, including players and coaches who want to play so badly that they minimize symptoms, skeptics who wonder why concussions are suddenly a big deal, and large numbers of parents who want to exercise caution after a blow to the head but don't know what to do. Now is the time capitalize on current concussion awareness and overcome these obstacles.
It's sometimes obvious from the sideline when a player is concussed, like with my son's teammate, Owen. We watched as one of his quarterback carries was stopped by a seemingly unremarkable tackle. His immediate ataxia when he got up, however, was quite remarkable. Even the most obtuse knuckle-headed parent could see he wasn't right when he veered to one side with the balance of a drunk as he walked off the field.
Sometimes, a concussion is more subtle, like with another of my son's teammates, Henry. No one would have known anything was wrong from the sidelines. His coach, fortunately, noticed he had “funny eyes” when he got up after a fierce hit. Henry was A&Ox3 but said he felt dazed, and the coach's description to me of “funny eyes” sounded like nystagmus. Subtle cases like Henry's are common. A majority of concussions (90%) don't involve loss of consciousness. A player should not return to play the same day if there is any question on the sideline of any possible signs of concussion. Bottom line: If in doubt, take them out.
What about athletes not as forthcoming as Henry or parents and coaches not convinced he should stop playing? All 50 states have some form of concussion law we can reference to convince parents, coaches, and kids that players should come out. Likewise, the widely taught second impact syndrome is useful for convincing concussed players to rest (even though no good evidence supports that it exists). New school concussion tools can also be used on the sideline to replace the two-fingers approach: The pocket Concussion Recognition Tool (CRT) seems most amenable to sideline use, and Child SCAT3 is another tool to provide objective data that a child should not play.
It's up to us not only to be leaders in sideline diagnosis, but also to promote better treatment of concussions by educating patients and communities. Most kids will only see us in the ED after a head injury and not follow-up. Not one of 100 patients evaluated in the ED for concussion followed up with another provider one month later. (J Emerg Med 2011;40:262.)
We must take the lead in teaching the approach to recovery. Any player with a concussion should go through five steps: an initial period of rest, light aerobic activity, noncontact drills, full-contact practice, and then full-contact games. He can advance to the next step after 24 hours without symptoms during the previous step but should drop back if symptoms occur. (Perron A. “Concussion Update 2015.” ACEP Presentation: Boston, MA.) If necessary, serial post-injury neurocognitive testing can help indicate resolution of cognitive impairment.
People ask how I let my sons play football. My answer: It's their passion, and it teaches positive life lessons. I'm more fearful about what they do off the gridiron, like when they get their driver's license or go to parties where there are drugs and alcohol. We know that life is a matter of inches and seconds, and catastrophic accidents can happen anywhere, so we might as well pursue our passions. Coaches and referees at least watchfully chaperone on the football field. We can enjoy being boisterous, impassioned fans while our kids play the greatest game as long as we are simultaneously vigilant. To protect their heads we need to use ours.