Article on Fed concussion rules.

[Jason Kramer]

http://www.footballoutsiders.com/extra-points/2010/nfhs-steps-backward-concussions

Good critique of the Fed's new concussion rules.

NFHS Steps Backward on Concussions
The National Federation of High School Associations handles officiating in a very similar fashion to the NFL: Each year, certain rules are reexamined and modified, and points of emphasis are issued. These changes and emphases are sent out to high school officials, coaches and directors in various publications. Considering last year's firestorm over concussions, no one was surprised when the NFHS decided to put "concussion recognition and management" on the top of the points of emphasis. Beyond that, however, a rule change was in order.
3-5-10b
A timeout occurs when an apparently unconscious player is determined by the game officials. The player may not return to play in the game without written authorization from a physician (M.D./D.O.). This time-out, if not charged, is an official's time-out.
There were a lot of problems with the old rule's language; "apparently unconscious" gives the officials authority to remove concussed players from the game, but the vagueness of "unconscious" left officials out on a limb whenever a player was conscious and partially responsive. The new rule allows officials to remove players who show signs, symptoms or behaviors consistent with a concussion. This may seem like a small change, but the NFHS has a medical committee which publishes very specific guidelines regarding concussions. Everyone is finally on the same page.
The NFHS sadly took a step backward in the "enforcement" section of the rule. Where before a player could only reenter play with written authorization, a player may now reenter play after being "cleared" by an appropriate health-care professional, as defined by the host state. "Cleared" is left undefined, but the rules committee made it clear that it no longer means written authorization. This change seems pretty benign, until you read the examples which accompany the new rule, which officials rely upon for interpretation:
With 4:37 to play in the first quarter, A1 exhibited signs of a possible concussion and was sent out of the game by the officials. When the second quarter begins, A1 is sent back into the game.
Ruling: Legal. If A1 returns, the officials are to assume an appropriate health-care professional approved, as re-entry is a coach's decision. However, if A1 again shows signs consistent with a concussion, he should be sent off again.
There is a world of difference between written authorization from a licensed professional and the assumption that a player has been "cleared." A written authorization has the doctor's name, the player's name, and enough important facts to create a clear paper trail, both to protect the doctor and to allow the officials or parents to complain to the state association should a player be sent back into the game before it is safe. Of course, moving re-entry solely into the realm of "coach's decision" really turns medical clearance into kabuki theater:
A1 sustains a hard but legal hit and is slow to get to his feet. When he does rise, he holds his head and has trouble keeping his balance. The officials send A1 off the field. There is no appropriate health-care professional on site. A1 is sent back into the game after sitting out one down.
Ruling: Responsibility for A1's return falls on the head coach. The officials are not required to determine if an appropriate health-care professional has examined and cleared A1.
So, officials are to assume players have been checked, that they have been cleared, and even if there is no one there to clear the player, stick their heads in the sand. While making it easier for officials to remove a player from play, the NFHS at the same time has made it far harder to actually keep injured players out of the game. Faced with an unscrupulous coach, in fact, the officials have no recourse save repeatedly removing the player and making him sit out one play at a time, which is almost certain to end badly for the official -- reentry is a coach's decision, remember?
While the rest of the football community is taking a hard look at concussion management, high school players -- the most vulnerable players with the least control over their fate -- have been stripped of what little protection they had. Reentry can have serious consequences for a concussed player, including paralysis and death. That the NFHS has essentially put concussion enforcement on the coach's shoulders just shows how far we have to go on this deadly serious issue.
I called the NFHS to get an official explanation or statement about the new rule, but they did not return my call.
Posted by: Will Carroll on 26 Jul 2010

[Mike L]

Actually it's not that good of a critique because the author is operating under an assumption that the written note really meant anything at all. How did you know who actually wrote the note? How do you know they are at all qualified to make any such evaluation? The unsrupulous coach could get around that just as easily as the author is worried about now by sending him back without any evaluation.
The new rule places 100% of the responsibility of returning a suspected concussed player on the school/coach, which I think is a good thing. If a school has a coach that is willing to put his players at risk like that, well there's really not much I could do before the rule change or after.

[Atlanta Blue]

I agree, the article is ridiculous.  The new rule puts the onus squarely on the shoulders of the coach.  Why should the official have any "more" say than the coach?  The VAST majority of officials have little or no training in concussion management, while the vast majority of coaches get training regularly on the subject.

In addition, most coaches aren't "unscrupulous", and if they are, there are ways around any of the rules.  he author assumes: "A written authorization has the doctor's name, the player's name, and enough important facts to create a clear paper trail, both to protect the doctor and to allow the officials or parents to complain to the state association should a player be sent back into the game before it is safe."  It's not it's written on a prescription pad - it may have been nothing more than a scribbled note on a hot dog wrapper.  How does that give the parents anything more to complain with to the state than they have now.  Now, if a parent feels the kid was wrongly returned to the game, we know the responsibility fell right on the head coach.  If wasn't smart (or "scrupulous") enough to get a health-care professional to clear the kid, then it's his butt on the line, not the official, so why should the official worry about it?

The whole premise of the article is ridiculous, narrow minded and just plain ignorant.

[HLinNC]

I replied with links from our 3 discussion boards where the topic has been discussed with our learned brethren.
Although under the Kentucky-Federation slip, I guess we aren't supposed to do that now>

[bama_stripes]

Any coach who allows a player to return without clearance from an MD/DO deserves what he will (eventually) get, IMO.  No single game, even a championship, is important enough to risk a kid's life.

[LAZebra]

All the coaches I have spoken with say they will only return a player to the game if physician clears them with written authorization.  Smart, (scrupulous) coaches will only return a player who is very clearly able to return.  Unscrupulous coaches would just have the cheerleader sponsor forge a note to put the player back in if a note were required.  Honest people are honest, dishonest people are dishonest.  Rules, laws, or moral codes do not change this fact.

[Atlanta Blue]

All the coaches I have spoken with say they will only return a player to the game if physician clears them with written authorization. 

We have 2, and sometimes three doctors on our sideline during games (one of the benefits of a private school - of course, a detriment is that we have 8 times that number of lawyers in the stands).  If I have a kid with symptoms, the doctor is going to check him out.  If the doctor tells me directly the kid is good to go, I'm not going to require a written note from that doctor.  The doc looked right at me and told me he is good to go, that's good enough for me.

What I won't do is take someone else's word that the doctor said he is good to go, nor will I make that decision myself.  But if it's straight from the doctor, I don't need a written note.

[mbyron]

Ohio requires written authorization from an MD, DO, or certified trainer before the player is allowed back in the game. The umpire is supposed to hang on to it -- according to our new mechanics czar, apparently for years.

[xkath]

Will meet with state interpreter this weekend, but I heard in California, the referee and umpire, in their pregame meeting with coaches, will ask for and record the name of the "appropriate health-care professional" for each team. This person may or may not be on site.

[HLinNC]

NC state clinic tonite advised that the "appropriate h-c professional" will be a Medical Doctor, no PA's, no athletic trainers.

[Atlanta Blue]

NC state clinic tonite advised that the "appropriate h-c professional" will be a Medical Doctor, no PA's, no athletic trainers.

Last month, Georgia said that it must be a MD or DO, but they also said that wasn't a final decision.  The problem with that ruling is that it will create a pretty broad disparity.  Doesn't matter for us, we always have 2-3 doctors on the sideline.  But if we play a city school, there is a very good chance they don't have a doctor readily available.  Would our doctors evaluate an opposing player?  If asked, sure.  They help on significant injuries to ANY player (or official) regardless of what team they are on.

But would an opposing team ask the doctor to come to their sideline, or bring their kid to our sideline for a concussion evaluation?  The predominant thought is no.  So a school like mine has a far better opportunity to get a kid evaluated and back in the game than does some of our opponents.

In addition, a Certified Athletic Trainer may have even more direct training on concussions than do some doctors, depending on their area of practice.  The mom of one of my players is an OB/GYN.  She will be the first to tell you she is no expert on concussions.  But one of our ATC's travels globally with the Womens' National Soccer Team, and has been a featured speaker at concussion symposiums all over the country.  I would take her concussion evaluation over the OB/GYN any day.

I think states that say "must be an MD" are taking the easy, or more specifically, the most easily legally defensible way out and not dealing equitably with the question.

[Fadamor]

I wasn't impressed with this article.  These notes are next to useless for an official, so the lack of them doesn't really change anything.  As has been previously noted, the unscrupulous coaches are going to send their star players back in whether a forged note is needed or not.  The officials aren't going to know whether that illegible scribble is an actual doctor's signature or the prom queen's.

Virginia State Legislature is working on a State Law that pretty much mirrors the NFHS rule.  The only question remaining for the VHSL is which medical professionals will be allowed to sign off on letting a player back into the game.  Once the state law delineates that, VHSL will use the same list.  As it stands RIGHT NOW, however, athletic trainers are not part of the group who could sign off.

We were also told in our VHSL State Rules Clinic to NOT use the word "concussion" when talking to the coach if a player gets sent off.  The gist of the instruction was,

"Even if you are a doctor in real life, you are not on the field in the capacity as a doctor when you're officiating a game.  Official's are not to be performing medical diagnoses on players.  Simply inform the coach that the player needs to be looked at and describe the player's symptom(s) that caused you to come to that conclusion.  The coach is to take this as a head's up that the player needs to get evaluated before he can re-enter the game."

[VALJ]

Just curious - was that from Tom Z or from Charlie, Fadamor? 

I've got my clinic tonight (I think Z will be the one doing it).  If we've had different clinicians, it would be interesting to compare the verbiage.

[Fadamor]

Tom did ours.

[VALJ]

Tom repeated that verbiage, basically verbatim.  "Don't use the word 'concussion', because you're not making the diagnosis.  Just tell the coach '78 came up woozy after that hit, coach - he needs to be looked at.'"

[Fadamor]

Good to see Tom is being consistent. We'll see how the new rule works out.  I just hope the schools are going to apply the same type of diligence during practices.  The kids are in practice a lot more than they are in games.

[Atlanta Blue]

Why would you NOT use the word "concussion"?  If you don't, you have no reason to remove him:

3-5-10-b: Any player who exhibits signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion or balance problems) shall be immediately removed from the game and shall not return to play until cleared by an appropriate health-care professional. This time-out, if not charged, is an official’s time-out.

You're not diagnosing a concussion, you're telling the coach you see signs, symptoms or behaviors consistent with a concussion.  "Coach, #82 is woozy" doesn't get it.  Woozy isn't anywhere in the "NFHS Suggested Guidelines for Management of Concussion".

"Coach, #82 is showing symptoms consistent with a concussion."  You aren't diagnosing a concussion, you aren't even guessing he has a concussion.  You are removing him the way the rule tells you, for showing SIGNS consistent with a concussion.

Sure, if you go over and say, "Coach, #82 has a concussion", now you have overstepped your diagnostic abilities.  But the word "concussion" isn't the problem here.

[AlUpstateNY]

Personally, I don't see any reason to go past NF: 3-5-10-a as justification for sending a player to the sideline for evaluation, under any circumstance where any possible injury is suspected.  Under that rule section, "whoozy" or any similarly vague term fits the situation and notification objective perfectly and eliminates all the semantics nonsense.

The primary objective remains, as it has always been, when confronted with just the possibility that a player might be injured, or otherwise physically endangered to participate they be temporarily removed from the contest and evaluated before being allowed to participate. Rule makers repeatedly seem confident to rely on the common sense judgment of game officials to act both reasonably and responsibly.

NF: 3-5-10-b, doesn't supercede or replace 3-5-10-a it merely calls for special attention to be paid to a chronic possibility.   

[Atlanta Blue]

Personally, I don't see any reason to go past NF: 3-5-10-a as justification for sending a player to the sideline for evaluation, under any circumstance where any possible injury is suspected.  Under that rule section, "whoozy" or any similarly vague term fits the situation and notification objective perfectly and eliminates all the semantics nonsense.

The primary objective remains, as it has always been, when confronted with just the possibility that a player might be injured, or otherwise physically endangered to participate they be temporarily removed from the contest and evaluated before being allowed to participate. Rule makers repeatedly seem confident to rely on the common sense judgment of game officials to act both reasonably and responsibly.

NF: 3-5-10-b, doesn't supercede or replace 3-5-10-a it merely calls for special attention to be paid to a chronic possibility.   

But here's the problem with that - if you send him out under 3-5-10-a, a doctor's (or "Appropriate Health Care Professional's") approval is NOT required for him to return.

If you send him out under 3-5-10-b, the doctor's approval IS required.

If you send him out under 3-5-10-c, then no approval is required, but the blood has to be cleaned up.


So unless you tell the coach you are removing him for concussion signs or symptoms, the doctor's approval doesn't kick in.

I understand the Virginia clinician not wanting people to say, "Coach, this player has a concussion."  But it seems to me he HAS to say, "Coach, he has symptoms (or signs) of a concussion."

[AlUpstateNY]

With all due respect, I think you are picking atthis from a gnat's eyelash and purely semantic level.  When we send a player out because of a physical concern, it has always been for the purpose of having the player evaluated on the sideline.  This year's modification doesn't change that in the slightest. 

When we remove common sense from the reality of any of the game's rules, we open a pandora's box.  Every rule is written on the basic foundation that those assigned the responsibility for insuring that any rule is complied with, either from an instructional or enforcement perspective, do so with the legitimate interests of the game and the safety of the participants in mind.

[Atlanta Blue]

With all due respect, I think you are picking atthis from a gnat's eyelash and purely semantic level.  When we send a player out because of a physical concern, it has always been for the purpose of having the player evaluated on the sideline.  This year's modification doesn't change that in the slightest. 

Changes it completely.  You have three rules with which to send a player off:

a - an "apparently injured" player
b - a player with concussion symptoms
c - blood on player or uniform

A and C do NOT require a doctor's approval to return.  B does.  So unless you tell me you are sending him off for concussion signs, my approval is the only one needed for him to return.

If you think it's concussion signs, just say so, and the liability is removed from you.  If you send him off for "being woozy" without saying it's a concussion sign, you are potentially setting yourself up for liability.

Officials now have a VERY easy way of moving the concussion liability totally onto the coach, and that is by invoking "signs of a concussion".  I don't understand why anyone should fear using those words, it's ridiculous not to use them.  If I were officiating and kid was limping on a twisted ankle, I'd tell the coach it was a sign of a concussion! 

[bama_stripes]

If I were officiating and kid was limping on a twisted ankle, I'd tell the coach it was a sign of a concussion! 

How much respect would you have for an official who told you that during one of your games?

[Atlanta Blue]

How much respect would you have for an official who told you that during one of your games?

Well, I thought the wink would let you know I was being facetious, but it was done to make the point that if there is ANY question as to why you are removing a player, invoke the "concussion rule".  The Virginia directive to not use the word "concussion" is simply silly to me.  You aren't saying the kid HAS a concussion, you're simply saying you saw signs or symptoms consistent with a concussion.

[AlUpstateNY]

Changes it completely.  You have three rules with which to send a player off:

a - an "apparently injured" player
b - a player with concussion symptoms
c - blood on player or uniform

If I were officiating and kid was limping on a twisted ankle, I'd tell the coach it was a sign of a concussion!  /quote]

Sorry AB, your concern is just silly.  Perhaps I have more respect for the integrity of coaches than others, but if I send a player off for concern about being "apparently injured" I'm going to, usually, trust the coach I'm sending that player to, to respond professionally and do what he is required to do, which is assess the safety of sending that player back into the game.  I've done my job and delivered the player to the next required step in the review process.  I have no responsibility or authority to direct the handling of that next step but am confident the next step will handle their responsibilities appropriately.

If for some reason I'm dealing with a coach I don't trust, I'll find another coach I do trust, or adjust my handling to accomodate this exceptionall rare circumstance.

[mbyron]

You aren't saying the kid HAS a concussion, you're simply saying you saw signs or symptoms consistent with a concussion.

Exactly right. The new rules and procedures do NOT require us to diagnose anything (which would entail practicing medicine without a license).