A Safer Game Plan

Last season, three New Jersey student athletes died from injuries sustained on the playing field. Here’s what the state is doing to avoid future tragedies.

Illustration by Maxwell Holyoke-Hirsch.

Catastrophe is not supposed to befall a young, fit, seemingly healthy athlete. But last month marked the one-year anniversary of just such an event—a moment that left a high school, a community, and, in many ways, an entire state shaken and determined to prevent it from happening again.

On October 13, 2008, 16-year-old Montclair High School student Ryne Dougherty made a routine tackle during a junior varsity game against traditional New Jersey football powerhouse Don Bosco, a Catholic high school in Ramsey. Seven days earlier, Dougherty had been cleared to play by his family physician and a consulting neurologist after a three-week hiatus made necessary by the concussion he had sustained during a September 18 practice.

What neither of his doctors knew when they cleared him was that Dougherty was still experiencing headaches associated with the September 18 concussion. Dougherty had not shared this crucial information with anyone except a few teammates who, out of loyalty or ignorance of the consequences, had kept his secret.

After the tackle, the young football player collapsed, stood up, then collapsed again. He was rushed by ambulance to the trauma center at Hackensack University Medical Center, where surgeons operated to relieve pressure on his brain caused by bleeding. “The goal in such cases is to prevent secondary damage, because whatever damage was done at the moment of impact is irreversible,” says Arno Fried, chairman of the department of neurosurgery at HUMC.

But physicians who treated the injured boy were waging a losing battle; despite its apparent ordinariness, Dougherty’s tackle had caused a second concussion. Because the symptoms of his first concussion had not abated, he now faced a situation that brain specialists refer to as second-impact syndrome—in which the brain becomes susceptible to even greater swelling and bleeding, resulting in pressure inside the skull that can literally squeeze the brain to death. After two days of trying unsuccessfully to alleviate the destructive pressure, doctors received permission from Dougherty’s family to remove life support.

Ryne Dougherty was not the only New Jersey student-athlete to die in 2008. Two months earlier, two other young New Jersey football players had passed away barely one day apart. The first was Sean Fisher of Waldwick, a 13-year-old who had been participating in a youth recreational league when he went into cardiac arrest—an immediate, unexpected loss of heart function, breathing, and consciousness, typically caused (as in Fisher’s case) by an undetected pre-existing heart condition. The second was 17-year-old Douglas Morales, a Cliffside Park High School student who died as the result of a head injury sustained during a routine football drill.

Unlike the bumps, bruises, cuts, sprains, and simple fractures that most people accept as an inevitable part of athletic competition, catastrophic sports injuries, especially in young athletes, seem to violate the natural order of things. “Sports are supposed to be about good health and camaraderie, so we never expect that they will result in tragic situations,” says Barbara Geiger-Parker, president and CEO of the Brain Injury Association of New Jersey, which has spearheaded a Concussion in Sports campaign to raise awareness and push for better pre- and post-concussion management.

Over the years, better equipment, stricter rules, more enlightened coaching, and keener medical supervision have significantly reduced the number of catastrophic injuries in youth sports. Though rarer today than ever before, such injuries continue to be the stuff of nightmares for parents, coaches, trainers, team physicians, and school administrators.

Nationally, as in New Jersey, football leads all high school sports in the number of annual catastrophic injuries, although “the incidence per injury per 100,000 participants is higher in both gymnastics and ice hockey,” according to the most recent injury report from the National Center for Catastrophic Injury Research at the University of North Carolina in Chapel Hill.

In 2008, seven U.S. high school athletes died from injuries directly related to football; in five of these cases, including the two in New Jersey, the cause of death was traumatic brain injury. The other deaths were caused by an abdominal injury and a chest injury. There were also seven indirect football-related fatalities in U.S. high schools last year. Heat stroke was the cause of death in four of the cases; in the remaining three, heart-related problems were to blame.

High school football—almost exclusively a boys’ sport—also accounts for 60 percent of all youth sports-related concussions, according to the Centers for Disease Control and Prevention. For girls, by contrast, soccer is the leading cause of sports-related concussions. In fact, in a study of 100 U.S. high schools published in 2007 in the Journal of Athletic Training, researchers found that girls who played soccer sustained concussions 68 percent more often than boys who played the sport. In high school basketball, another sport played by both sexes, researchers found that the concussion rate for girls was almost three times higher than the rate for boys.

For concussed athletes, the dangers of returning to play too soon are real, as the case of Ryne Dougherty clearly demonstrates. Despite this, a surprising number of students suit up again before they are completely symptom free, as shown in a study by the Center for Injury Research and Policy, part of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio.

In the study, researchers analyzed data from a sample of 100 U.S. high schools to determine athlete adherence to return-to-play guidelines of the American Academy of Neurology, as well as other groups. At least four in ten concussed athletes who returned to play did so too soon, based on AAN guidelines, the study found. What’s more, during the 2007-2008 season, “One in six football players who sustained a concussion and lost consciousness returned to play the same day.”

To counter this trend, some 20 percent of New Jersey’s public, private, and parochial high schools now use concussion-management software to guide their return-to-play decisions. Efforts are also under way in the state to prevent other serious sports-related injuries, including those stemming from hypertrophic cardiomyopathy—a congenital thickening of the heart muscle and the leading cause of sudden cardiac death in young athletes. The New Jerseyans involved in these and similar prevention efforts span a broad range, from physicians and trainers to coaches and school administrators. Stunned and saddened by last year’s series of untimely deaths, many have approached their mission with a renewed sense of purpose and a conviction that even one athlete dying young is one death too many.

At Montclair High School, the shock of Ryne Dougherty’s death still lingers a year later. “The football players—they don’t show it, but you know it’s still a big part of what’s going on inside them,” says John Porcelli, assistant principal in charge of athletics and student activities. The events of last October are also never far from the minds of school officials, who, in the year since Dougherty’s death, have been forced to take stock. “We learned a great deal from a very tragic experience last year,” writes Frank Alvarez, superintendent of the Montclair Public Schools, in an e-mail. “As a result, we have implemented several new measures to protect our students.”

Chief among these at Montclair High School this year was to make sure that all athletes—football players and non-football players alike—received an ImPact test. Developed at the University of Pittsburgh Medical Center, ImPact is a computer-assisted concussion screening program that establishes a range of neurometric and neuropsychological data for each athlete prior to the start of competition—and, ideally, prior to the start of practice. The test establishes baseline data in such areas as word recognition, visual recognition and recall, visual processing speed, and impulse control. To measure impulsivity, for example, the test displays on the screen, in random order, the name of a color written in that color—“RED” in a red font, for example—and in other colors. (A pre-test screens for color blindness.) The test subject is then instructed to click on the word as rapidly as he or she can only when it is flashed in its correct color.

Any athlete who sustains a concussion during the season can be retested, with physicians and trainers comparing his or her new data with the baseline test. If an athlete has not returned to baseline in the critical areas measured by the test, he or she will almost certainly be kept from participation. “If you don’t have any data, you have to rely on the patient’s subjective opinion—and lots of times, especially in young people, that is colored by their feeling of immortality and their desire to get back to doing what they were doing,” says neuropsychologist Gerald Tramontano, clinical director of the NeuroRehab Institute in Mt. Arlington. “Baseline screening”—ImPact is only one of a number of such programs available—“gives us a metric-based approach to help us make those types of decisions.”

ImPact testing was instituted at Montclair High School last year, when the school became one of the 100 or so New Jersey high schools to receive a $650 matching grant from the Brain Injury Association to start baseline screening. The grant was received in October, at which point the athletic season was already under way. As a result, some but not all football players were tested. (In addition to football, the school has more than 30 other varsity sports.) “Once the season starts and athletes are already exerting themselves, it’s hard to get valid baselines,” says LaDawn McClamb, an athletic trainer at Montclair. As the year went on, says McClamb, more athletes, including those in other sports, were scheduled for testing.

Ryne Dougherty, who had been practicing with the JV squad as late as September 18, was among those who were not tested. Had he been, it is possible that his post-concussion results would have deviated so far from national norms that his physicians would have been alerted to his true condition. No one can say for sure—but Montclair officials are taking no chances.

“This year, we made more of an effort to get as many of our athletes in prior to them starting practice,” says Porcelli. He credits his two athletic trainers for moving the program off the dime so quickly: “When you have to deal with 400-plus youngsters and have them sit for 40 to 45 minutes at a computer, it’s not easy.”
Besides beefing up ImPact testing this year, Montclair plans to hold at least one workshop on concussions in adolescence for parents, whom Porcelli and others believe are key links in the chain of proper concussion management. “Everyone,” Porcelli says, “including parents, needs to understand that an adolescent concussion is a lot different from an adult concussion”—because the adolescent brain is still developing and may take longer to heal.

The parent workshop will build on a similar one held last year for coaches, trainers, and other Montclair school personnel. The presenter—whom Porcelli hopes to bring back—was Dr. Dean Filion, a Rutherford-based physical medicine and rehabilitation specialist and a member of the medical staff of the pro football Giants. Among other things, Filion offered attendees a primer on second-impact syndrome, which many in the audience, including Porcelli himself, had never heard of. The introduction to this often fatal condition—as well as to the proper management of concussions in general—proved a real eye-opener for many. “To err on the side of caution with youngsters is certainly the path we’re going to follow from now on,” Porcelli says.

In the year since Ryne Dougherty’s death, school officials have also endeavored to build a culture of trust, so that students who have vital information will be more likely to share it with an adult in authority. “There is a sense of loyalty they have to one another, and that’s very admirable,” Porcelli says. “But when it comes to someone’s health, they need to feel comfortable coming to an adult. After Ryne’s death, we stressed that. Our student assistance counselors talked to the kids about the issue—and I know the football staff talked to them about it as well. In both cases, the message was the same: It’s okay to come to an adult, even if you want to remain anonymous.”

McClamb acknowledges the difficulties: “Because we have so many athletes, it’s hard to develop a personal relationship with all of them. It’s especially hard to do with freshmen, who don’t yet know us well. I just hope all the kids realize that the game isn’t as important as how they’re feeling.”

In the aftermath of Dougherty’s death, such a sentiment is shared widely in the Montclair public school community, which hopes other communities will learn from its experience. Says Montclair superintendent Alvarez: “Our primary goal is… to protect our students. In the process, we’re hoping to set a standard for other districts to follow.”

Besides traumatic brain injuries, school districts across New Jersey are wrestling with how to prevent other catastrophic sports-related injuries, including spinal-cord damage, heat-related stroke, blunt chest trauma, and cardiac arrest.

Underlying heart problems present a special challenge, since they often go undetected until it is too late. Estimates of the incidence of sudden cardiac death in young people vary widely, from 1 in 100,000 to 1 in 300,000. Of the deaths that do occur, the most common cause is hypertrophic cardiomyopathy, a congenital disease in which the muscle of the heart (the myocardium) thickens for no apparent reason, in some cases causing an obstruction of blood outflow from the left ventricle.

Because this disease is “clinically silent,” as experts say, it is essential to screen for a personal or family history of a loss of consciousness (syncope), especially during exertion. Recognizing this, the New Jersey Department of Education, working with the New Jersey State Interscholastic Athletic Association, has issued new regulations for the state’s pre-participation medical form. “We increased the area devoted to medical history in an attempt to uncover evidence of a possible individual or family problem,” says Dr. Timothy Hosea, an orthopedic surgeon and chairman of the NJSIAA medical advisory board.

For young athletes whose pre-participation screenings turn up something suggestive, the next step might be a referral to someone like Dr. Christine Donnelly, director of pediatric cardiology at Goryeb Children’s Hospital at Morristown Memorial Hospital. Donnelly’s fuller work-up would include an EKG, to check the electrical activity of the heart over time, and an echocardiogram, which uses ultrasound technology to produce two- and even three-dimensional images of the heart.

In Europe, Donnelly says, EKG testing is a routine part of pre-participation screening. Should U.S. schools follow suit? Donnelly is skeptical, not only because of already tight health care budgets but because of the not uncommon problem of false positives, which prompt still further evaluations. Hosea agrees: “The way to go, I think, is to identify individuals at risk, and then test them further. This method of screening is certainly more cost-effective, and probably just as good clinically as testing across the board.”

For parents concerned that their son or daughter might be at risk, St. Barnabas Health Care System in West Orange sponsors periodic Playing with Heart cardiac screenings, which include a full medical history and an EKG. Past screening events have attracted an average of 150 participants. “If we can identify one young person at risk through all these screenings, we will have done our job,” says Dr. Donald C. Putman, chief of pediatric cardiology at St. Barnabas Medical Center and a leader in the Playing with Heart program. Information about the program and future events is available at 888-724-7123.

SIDEBAR: An Athlete Protection Playbook

No amount of effort is likely to totally eliminate traumatic sports injuries. But more could be done to prevent injury and better manage recovery. Among other things, experts say, we should:
Step up injury education.

This includes better education for parents, who might not always understand the risks posed by certain injuries such as concussions.

“Especially during the play-off season, parents whose son has sustained a concussion will sometimes accompany him into my office and say, ‘He’s good to go—he’s ready to play this weekend,’” says Dr. Jack Knightly, director of neurosurgery at Morristown Memorial Hospital and Overlook Hospital and co-director of Atlantic Neuroscience Institute’s Concussion Center. “Then I have the young man close his eyes and stand on one foot. It’s a balance test I use to see if things have reset themselves following a concussion. As soon as the kid closes his eyes, he’s all over the place. And that’s when I say to the parents, who by now are looking at me wide-eyed, ‘So your elite athlete can’t stand on his foot with his eyes closed—and you think he’s good to go?’” That demonstration, says Knightly, a hockey coach whose own son once sustained a bad concussion, usually ends the discussion quickly.

Increase baseline screening. The good news is that 20 percent of New Jersey’s roughly 500 public, private, and parochial high schools do baseline screening; the bad news is that almost 400 schools do not. “I think it is imperative for our athletes in contact sports and in other sports where athletes are at risk, to have baseline screening,” says Dr. Timothy Hosea of the New Jersey State Interscholastic Athletic Association.
Federal legislation sponsored by Congressman Bill Pascrell—the Concussion Treatment and Care Tools Act of 2009—would make money available to help schools throughout the nation establish baseline testing, among other concussion-related programs.

Place an athletic trainer in every secondary school. Nationally, 42 percent of secondary schools employ an athletic trainer, whereas the percentage in New Jersey is between 80 and 85 percent, according to the Athletic Trainers Society of New Jersey. But ATSNJ President Michael Prybicien, the head athletic trainer at Passaic High School, would like to see that number rise even further. “We’d like to get to the point where every athlete in a secondary school has access to an athletic trainer,” he says.

Why are trainers so important? For one thing, Prybicien says, they serve a vital role on game day. “All the coaches that I know care deeply about their athletes, but on game day their primary focus is on calling the right plays and winning the game. My focus is to make sure the kids are safe and that we aren’t taking any unnecessary risks.”

It’s also the role of the trainer, Prybicien says, to win athletes’ trust. Many will then come to him or her if they’re not feeling right. In cases where the athletes don’t, he says, “teammates have come to me to say, ‘Trainer Mike, Sam took a hit yesterday during the game, and he hasn’t been right since. Come to the locker room or we’ll get him up here.’”

Insist on competitive balance. Most observers agree that Montclair’s Ryne Dougherty did not die as the result of his public school having football powerhouse Don Bosco on its schedule. (Like other private schools with a reputation for fielding highly competitive sports teams, Don Bosco recruits from all over. That can give them a size advantage over public high schools.) The problem, it seems clear, was not the size or power of his opponent, but Dougherty’s own concealed condition. And yet, in the past, conference mismatches were enough of a worry that some in New Jersey supported state legislation to separate public and private schools, thereby making conferences more competitively balanced. The legislation failed, but the state took a second look at existing conference lineups—and made some significant changes.

Resist the win-at-all-costs mindset. “We’re attempting to change a culture,” says Jill Brooks, a neuropsychologist in private practice in Gladstone who works with scores of concussed athletes, both boys and girls. In her lectures around the state, Brooks fiercely advocates not letting the drive to win overshadow the other goals of athletic competition—teamwork, self-esteem, setting and achieving goals, and safe and sensible play.

Wayne Guglielmo reports on health issues for New Jersey Monthly.

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