The Sound of Ideas

Dear Diary,

Today I appeared as a guest panelist on our local PBS radio station, 90.3 WCPN in Cleveland, Ohio. I  participated in a call in show titled "The Sound of Ideas." Our topic was concussions in youth football. I was able to offer some ideas on the problem and have some fun in the process. The show also featured Dr. Joseph Congeni of Akron Children's Hospital, the president of a local youth football league (John Prochaska, his son Sam, and one other player on his son's team, Dylan Himmal.  Many issues were discussed and I thoroughly enjoyed my time. Below is the embedded link to the episode that I appeared on from their podcast feed.

(Click on the logo to go to website and download the episode or subscribe to their RSS/podcast feed)

Many thanks to Ida Lieszkovszky (producer) and to Mike McIntyre (host) for their generous invitation and hospitality today.

Seminar Season

It has been too long again since my last post. I am finding myself busy doing many other projects and this blog has suffered as a result.

Anyway, welcome to summer! 

As we get ready for the heat and begin preparations for the return of fall seasons, this is my chance as a high school athletic trainer to go out and continue to learn. I had the opportunity a couple of weeks ago to attend a conference in PIttsburgh, Pa. that was presented my the UPMC staff on concussions. 

The course was an update as to what has changed in the last few years and a glimpse of some of the more promising research for the future. I was particularly excited to see a demonstration of a new MRI technique that showed an extremely high definition picture of the the brain being scanned. The potential for this technology os extremely promising and it would be a welcome addition to the arsenal of diagnostic tools.

The most exciting thing that I heard that weekend is that there will be an iOS and android version of the new SCAT3 test available this fall.  I am hoping that the test will be released in the iTunes Store before August 1st, which is our start date.  However, there was no definite date given and it could be released much later in the season.  I guess I'll have to stick to the paper and pencil version for now.

The conference also pointed out that the SCAT3 does not include any testing for the vestibular system and it was the strong opinion of the UPMC crowd that this oversight needs to be corrected. Visual tracking and looking for nystagmus is one thing, but testing the cicadic movements of the eyes and other forms of visual tracking are also important. These additional tests don't require much more time or training to perform and should be included in an evaluation.

There was also some discussion about the upcoming and long promised pediatric version of ImPACT. A preview of the format was given and, as expected, it is more game like than the original adult version. There was a focus given to avoid reading as much as possible especially since this is designed to be taken by 5 year old children.

The thing that surprised more than anything with ImPACT is that they talked about being able to take the adult version of the test as early as age 10. Previously, I had heard that the minimum age was 13. However, the UMPC group did recognize that the normative data for this 10-12 year olds needs to be separated out from the adult scores since there is a large difference in the scores.  Needless to say, I am happy that I will be able to offer the test to my middle school children now, but that does involve a lot more work too.

Now I did say in my opening paragraph that this was about summer seminars. The other big seminar I am attending this year is in Las Vegas for the National Athletic Trainers Association convention. In fact, I am writing this blog post while en route. I hope to have more to share after what should be a fun week in sin city.

Youth Coaches and Their Reactions to HB 143 in Ohio

So far, the responses that I have received regarding the implementation of HB 143 (Ohio's Zachary Lystedt law for youth concussions) have been greatly mixed. The responses have ranged from mildly excited, completely apathetic, and more than a few people were reluctantly accepting of it. It has been greatly humbling, and at times, depressing to see these mixed reactions. While this is a topic that I care so deeply about, most people I have met with are simply trying to shrug it off and move on.

The situations that I worry about most are the parents that will fight and argue to their dying breath that their kid is not concussed despite obvious signs and symptoms that the child displays. I have heard far too many times from parents that "They care most about player safety." and "Safety always comes first." That is, until the score appears to dictate different priorities and that same parent denies that an injury could ever happen to their child or their teammates.

Please forgive me if I hold judgement on how effective this law is until I see how parents will react when it is their child that I am holding out of a game because they have some symptoms that generate concern. I have a feeling that more often than not, this will lead to much more confrontation between the parents, coaches, and myself from those individuals that still fail to understand the potential severity of concussions and second impact syndrome.

Certainly, our educational efforts need to continue if we are to have any hope of alleviating these confrontations as much as possible. However, my experiences tell me that this new law will not change the attitudes of far too many people who will still allow themselves to be too caught up in the score of the game when it matters the most.

I guess all I can do is hope that I am wrong about these assumptions. I will also hold out hope that this new law starts to open some eyes to the potential disasters that concussions can make of promising young lives.

Ohio's Concussion in Youth Athletics Law

On December 20th, 2012, Governor John Kasich signed House Bill 143 into law in Ohio.  This is Ohio's version of the Zack Lystedt law that regulates youth athletics when a concussion is suspected by the adults in charge of the program.  This law provides for the following provisions for youth athletics in Ohio:

All parents and athletes must receive information that includes the risk involved with participating in their chosen sport as it pertains to concussions. This pamphlet is to be designed and distributed by the Ohio Department of Health.

All coaches and officials (including HS and MS officials) must attend a course on concussions every three years.  They have two options available to them to complete this requirement.

1. They may attend a local Pupil Activity (PAP) Permit program that all high school and middle school coaches are already required to attend every three years. This option incurs some costs to the individual that include the application fee to the Ohio Department of Education (currently $45) and whatever fees the provider of the course charge (commonly about $20). As a condition of renewing the permit, HS and MS coaches ALSO have to complete the online program below.
2. This PAP can be cost prohibitive to many volunteer parents to coach in their son's or daughter's league. They are required to take a class approved by the Ohio Department of Health (ODOH) which are posted at http://bit.ly/WDPpcU. This list of approved classes is required for ALL coaches and ALL officials.

• It needs to be noted that these non-PAP classes will allow the individual to coach any level of competition that is not sponsored by the Ohio High School Athletic Association (OHSAA). These classes will not substitute for the PAP for HS/MS competition.  Any HS/MS coach that does not complete the PAP program is ineligible to sit on the sidelines for competition and risks the school being penalized $250 per incident.

Any kid that displays signs and symptoms of having suffered a concussion must be immediately removed from practice or competition that day.  They may not return until they have been cleared by a physician or a healthcare provider working under the direction of a physician.

• This can create some problematic scenarios where a healthcare provider may try to clear a person without proper direction in place.  This was designed to prevent many alternative medicine persons from trying to act independently and return a kid to play inappropriately.  However, the lawmakers did recognize that having a physician attend every practice and game in the state is not only expensive, but also inappropriate.  Therefore, the legislature allowed other healthcare providers to have this authority to do so.  Most other states designate these other providers as athletic trainers (ATs), physical therapists (PTs), registered nurses (RNs), physicians assistants (PAs), emergency medical technicians (EMTs), etc.  Ohio did not want to get caught in the political struggles of these professional groups when writing this law, so they allowed the physicians to decide who is qualified and who is not.
• An interesting point will be that physical therapists are not required to be under the direction of a physician in Ohio any longer.  It is possible that a PT (most likely a private practice PT) may try to return a child to play without having a physician contract behind them to do so.  This PT would be at serious risk for sanctions if they do so.
• PTs are not the only ones that risk this issue.  It is unfortunately very common for off duty nurses and EMTs to wander onto the sidelines during an injury situation.  I have had to tell more than one off duty professional that they need to return to their seat and allow me to do my job because they are putting my license at risk.  Many people do not trust that anyone else has the education and background to provide appropriate care in an emergency situation, and in particular, athletic trainers.  However, even athletic trainers need to have a contract with the team or league and a physician in order to allow then to perform their duties.  This can lead to some very sticky situations if the letter of the law is not followed.
• However, there is a provision that allows any organization (OHSAA) to have a more stringent set of rules than this provision in the Ohio Law that defines who is allowed to return a child to play.  This law allows the OHSAA to continue to restrict this list of medical professionals to MDs, DOs, and athletic trainers.  This can also create a point of contention with other health care providers who may believe that this state law gives them the authority to return a child to play under this law in HS/MS events.  It does not allow anything to change at these OHSAA sanctioned events.  

Coaches and officials can be held liable. Coaches of non-scholastic teams and officials can be criminally prosecuted and imprisoned for up to 30 days for "willful and wanton misconduct." Needless to say, this is a strong deterrent to allowing a child with questionable symptoms to RTP.

The problems with the new law occur when the child participates in multiple leagues or sports or is active at home in unsupervised play.  No law could prevent a child from heading out into the back yard with their siblings and neighbors and climbing the jungle gym, jumping on the trampoline, or playing a pick up game of baseball when they shouldn't.  This is the sole responsibility of parents and guardians of the child and it must be taken seriously.  However, this becomes a bigger problem for volunteer coaches when a child sustains a concussion in a travel baseball practice in the morning or even in some unsupervised activity.  The coaches may follow all the rules and do everything properly there so there are no issues.  However, if the child then participates in a hockey game that evening and the coaches are unaware of the earlier issue, then you have a major problem.  Obviously, the coaches could not be held liable for something they have no knowledge of, but what are the parents'/guardians' responsibilities and liabilities?  It is very easy for me to believe that  parent would allow a kid to play in the game that evening, especially if it is "important to that season."  I see that excuse far too often.

Another problem with the law is that is does NOTHING for the academic issues that a child may face after sustaining a head injury.  It is well documented (and should be fairly obvious) that there are often cognitive deficits that occur after a concussion that make schooling significantly more difficult for the child.  There is also some research that indicates that continuing to "work through" and not allow for rest and healing from cognitive stresses can increase the length of time that it takes to recover from the injury.  It is therefore up to the parents and the school to communicate these issues with each other and to make sure the child appropriately taken care of.  There is a large range of accommodations that can be made for these children, but that is the topic of another post.

The last problem that was brought to my attention by a lawyer who tweeted me.  He said the trial lawyers are going to have a "field day" with this new law.  The "willful and wanton misconduct" clause leaves a lot of room for interpretation by prosecutors and juries to determine whether or not a coach is going to be held liable for a child's injury.  While I agree that this is very subjective, I can't think of a better way of doing this.

In conclusion, most interested parties in this this process are happy to see this law pass.  The effective date for this will be April 26th, 2013, which happens to coincide with National Athletic Trainers Month.  It will be very easy to help promote both the profession and this new law in Ohio when it goes into effect.  The Ohio Athletic Trainers Association is already working to promote both ATs and the law and has encouraged their members to share this video to explain the importance of athletic trainers in this process. Of course, this could also bring a large amount of attention to the lack of athletic trainers in schools across Ohio and increase the job market opportunities for ATs.

• For more information on what a concussion is, please refer to this video that was produced by the National Athletic Trainers Association in partnership with the National Hockey League.