Concussion risk

Discussion in 'Referee' started by Bubba Atlanta, Dec 10, 2012.

  1. Bubba Atlanta

    Bubba Atlanta Member+

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    There's a lively discussion going on SOCREF-L about legislation pending in Ohio that would require youth soccer referees (among others) to be trained/certified on concussion evaluation. Meanwhile, here's a very interesting NY Times article about the ongoing NFL concussion litigation and the trickle-down effects it might have on sports generally, including youth sports.

    What do you guys do in a typical youth club match when players bang heads hard, shake it off, and say they're OK and want to continue to play? Other thoughts on the subject generally?

    Here's an AP article about the new Ohio rules: "Coaches and referees who are responsible for removing players with concussion symptoms must complete an online concussion education course every three years."
    Alberto repped this.


  2. fairplayforlife

    fairplayforlife Member

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    This frankly, is annoying. Why should the referee have one more thing they need to take care of on the game? Aren't there ups of 30 or 40 parents, sometimes 6 or so coaches there that all have at least a passing interest if not a fiduciary duty to protect their children from harm. If the coaches or parents want to send the concussed child back in to the game, then that is their problem, no matter how deplorable we might see the behavior as being.
  3. camconcay

    camconcay Member

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    And I would imagine Ohio is going to up the pay commiserate with at least a physicians assistant if not a general practitioner, provide malpractice insurance on top of the liability insurance, and require a CRA (concussion referee assistant) to monitor all players and inform the referee when someone needs to be evaluated.

    This kind of over reaction ticks me off to no end, not just referee related but any throw away legislation that "sounds good" so it will fly through with very little consideration to the end consequences. No one wants kids to get concussions or if they do no one wants them to play and get hurt worse - 100% agreed so lets make a law, we will all look great and what the harm?

    In this case I can almost guarantee that not a sole voting on this has refereed a single minute, so for them it's easy to add such a simple thing to our plate - the referees want to protect the kids, everyone wants there to be no concussions and if so to not play, so yeah - the referees can manage this little simple thing especially after watching a web thingy training thingy we pay our buddies $$MILLIONS$$ of tax payer dollars to come up with.

    Arghhhhh - sorry, /rant
  4. Cliveworshipper

    Cliveworshipper Member+

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    If I were expected to make medical evaluations, I'd expect malpractice insurance coverage as part of the referee insurance package. Time for Ohio referees to have that discussion.


  5. socal lurker

    socal lurker Member+

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    From the new law:

  6. nicklaino

    nicklaino Member

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    There is a handout for coaches on what to look for on concussion injuries are suspected. Not all coaches checks for them so it id good that the officials should have to look for them also. What are we here fore any way.I think the officials should let the game flow and call fouls so to help the player be safe. I think this is part of that.


    I will make two posts on this now, but first on Medical trainers. An older team can get a young kind training to be a medical trainer for free or very cheap. They need and are looking for some practical experience. They want to do older teams, so if you do some looking chances are you can get one.

    First post is a post I made on a coaching list. Officials can do the same.

    "These are tests that a coach should give a player after any kind of head injury. The player saying he or she is okay is not good enough.
    ------------
    Immediate past memory test - Ask them to describe what just occurred in the game before the hit. If they don't remember, they fail.

    Current thinking test - older players have them count backwards by 7s. Younger players just count backwards. If they cannot, they fail.

    Ability to retain new memories - Ask them to remember 3 random words (e.g., apple, car, Cleveland). If they cannot, they fail.

    Exercise test - If they cannot do 5 pushups without feeling
    woozy, then they are out for the game.
    --------------------
    Each year, several players in various
    sports die after second-impact concussions. The second-impact doesn't have to be the same day, or even the same week. Apparently, as long as the player has symptoms there is still some brain injury which needs healing. So there is a danger of making the condition worse if they get another head injury after the first.
    -------------
    Watch out for nausea, dizziness, ringing in the ears, headaches, confusion, sensitivity to light, erratic behavior or there vision changes in some other way. They should see a doctor and or neurologist, maybe even a trip to emergency on a knock out injury for a catscan to check for bleeding under the skull which can kill you"

    Next post was in answer to my post by a medical trainer.

    "Concussions are often brushed aside in athletics as trivial and players are often encouraged to push through the symptoms. This attitude is slowly changing as concussions are becoming more fully understood, and screen/evaluation tools are becoming more widely used.

    A concussion is an alteration in mental status caused by a traumatic force to the brain which may or may not cause a loss of consciousness. The early symptoms include: headache, impaired attention, speech problems, incoordination, disorientation, memory problems (retro/antro grade amnesia), and any LOC. Later symptoms can include: dizziness, nausea, vomiting, tinnitus (ringing in the ears), sleep disturbances. Pupil reaction/size is rarely indicative of a concussion although if the pupils are different sizes this is indicative of a more serious brain injury. Second impact syndrome occurs when multiple concussions occur within a short period of time. It is caused by swelling of the brain which results in a great increase in intercranial pressure. This is the main reason that concussions must be so closely monitored.

    Early recognition/assesment of concussions is essential. Headaches are normally the most reported symptoms. What Nick Laino outlined is good for a quick assessment suitable for the sidelines by a non-medical personnel. I would make one change, exercise testing is the last thing done and is only done if all the other things are normal. Push-ups are okay, but sit ups are better. The goal with exercise testing is to mimic the valsalva maneuver which increases intercranial pressure. Sprints and other types of running are not used as they actually lower the ICP and will decrease the symptoms. As an ATC I use both the SAC and IMPACT tests. The SAC test is a quick test that assigns an objective value to the symptoms. This is used on the sidelines, while the IMPACT is used to determine when it is safe to return the athlete to play.

    Both tests are also used as pre-season screening tests. This will establish a baseline value which can be used to compare to the post-injury test to determine the relative severity of the concussion.

    In terms of returning to play, it is based on the symptoms. If the symptoms resolve within 15 minutes the symptoms do not return with exertional testing, and their SAC scores are within 1 point of their baseline they can return to the game. If the symptoms persist for longer than 15 minutes they are not allowed to return and are evaluate the next day. If any LOC occurs they must be cleared to participate by a doctor. Bear in mind that these are guidelines used by doctors and ATCS alike and should not be implemented by someone without medical training. Generally, if a concussion occurs and medical personnel are not immediately available it is better to error on the side of caution and require a doctors release. This is often required in the case of high school teams depending on the school's specific guidelines.
  7. Alberto

    Alberto Member+

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    I haven't refereed a youth match in many years, but when I use to as I do with adults, I ask the player a few pointed questions.

    Do you know what day of the week it is?

    Do you know what time it is?

    What's today's date?

    What is your name?

    If the player is having issues remembering that's a sure sign they have suffered a concussion.

    If a player has blurred vision and if a player suffers from a headache and or nausea you should be aware that they are all concussion symptoms. Do not allow them to play.

    If they are very young and incapable of evaluating with the above questions ask them to look at you and to follow your finger while you move it around.

    Lack of awareness, loss of memory, loss of fine motor skills are all bad signs. Do not allow any player back into the game. Tell the coach parent they need to go to the hospital and have the player evaluated.

    A concussion is trauma to the brain. It is serious business.Players that come back too soon following a concussion face a greater risk of injury both short term and long term.

    Presently, several universities are conducting post mortem pathological studies on the brains of American football players. The results are not very promising for football players. Repeat concussions are causing dementia like symptoms very early after players have retired. Many have these symptoms in their early 40's.
  8. techguy9707

    techguy9707 Member

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    One of our board member's daughter is about 16 years old. She was injured in a tournament game about a week ago. She is still showing signs of her concussion and is attending school half days.

    It showed me how close every player is to a concussion, one play is all it takes.
  9. Bubba Atlanta

    Bubba Atlanta Member+

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  10. camconcay

    camconcay Member

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    I appreciate the tips and how to's - and our high school referee group has provided "training" as well. I am 100%+++ for protecting players and trying to keep them safe. I am extremely reluctant to go anywhere near the level of testing etc that some have suggested. I am very sad to say that in today's world all it will do is open you up for a world of lawyer hurt.

    In high school we can refuse to let a player participate if they exhibit signs of concussion and unless "medical personnel" releases them to play they don't in that game. We are not tasked with obtaining any kind of proof that the person vouching is qualified, only that they state they are so I guess thats HS way of getting us out of legal responsibility without really doing anything.

    For club or other events I honestly don't know where we can draw the line for concussions. Bleeding is clear - the USSoccer site has a 2010 article on concussions (several more older ones) not specifically mentioning any role (coach, referee) and says when in doubt, sit them out but relies I guess on common sense and isn't a directive unless a player loses consciousness.

    If there is any chance of a head injury I will ask the player directly, making eye contact, if they are OK - if I think they are the least bit shaky I will call the coach and they can make the determination. At least they will be out for a bit as the coach comes on so substitution is mandatory.

    If its a limited substitution game (I have only had a few ECNL games and thankfully no head injuries) I am not sure, I guess I would err on the side of not allowing them to play but if they say they are OK and the coach says let them play what do we do? What if we don't allow the star to play - they go to doctor and check out 100% ok and they lost the game - I would be OK making the decision but guessing that would be the last time I am assigned there.

    So what is our authority here?
  11. rkucenski

    rkucenski Member

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    Unless I am mistaken, no where in the LOTG does it provide for us to prevent or remove a player for any medical condition unless there is blood present. While I am all for player safety, I am not a trained medical professional. Whenever there is a moderate head injury, I will stop play and beckon the coach onto the field. Therefore now the player must leave the field until after the restart. This puts the player's safety on the coach/trainer.

    I don't see where we have any authority from keeping a player from playing due to a suspected concussion.
  12. nicklaino

    nicklaino Member

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    A little personal story on slip and fall. My daughter was comming home at about 11 pm when she was 18' she is now 36. I get a cell phone call from her and she is babble incoherently. I try and call her no answer. So I leave the house and start walking the route the way she usually comes home. I find her laying face up on the sidewalk.

    I call 911 and while I am waiting I am asking her tge concussion questions. She can't answer any of them. Now we get to the hospital and the rest of tge family shows up. She has two black eyes by then. It makes tge doctors believe she was punched in tge face or hit in the face by something. Now my son and I believed she maybe have been attacked by someone. Look through her purse her wallet and money are still there. Her clothes were not in disarray. Then we think maybe she had a fight were her boy friend. Being I have a paranoid personality I am thinking of shooting the bastard.

    Then I remember something and that something is if someone gets hit hard in the back of the head. Their eyes could go black which looks like she was hit in the face. I ask the doctor to check her face her nose, and cheek bones to see if they feel any damage. No damage so now they think she slipped and hit the back of her head on the concrete sidewalk.

    They give her the battery of tests. She was defibately light sensitive and they keep her over night for observation with a heart monitor that is part of tge procedure on knock out head injuries. But we can't talk to her rationally. She us yelling out everyone her family, the doctors and me. She wants out any way they calm her down.

    Then we leave in the middle of the night I wake up and I am worried so I drive back to the hospital at about 4:30 in the morning. As I get out if the car I see her leaving tge hospital. She pulled out the IV and just left . I bring her back. For months she was light sensitive and going to a neurologist. Imagine if I did not go back to the hospital that night.

    I posted this so you can see just how serious a concussion can be. My first post is a none doctor check for a concussion. I would imagine that is what the official is expected to do as well. It is not a big deal to ask an official to do. It is something every decent coach should do. Winning is very important but never that important if it goes against the well being of the player.
  13. camconcay

    camconcay Member

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    I agree 100%, but to my post, I cannot find where we have any authority (backed so far by rkucenski) to remove a player for suspected anything but blood/bleeding and if the blood/bleeding is corrected we must allow them back in. If I am to make decisions that trained neurologists and teams of medical personnel in medical facilities can miss, I just do not feel comfortable doing so on a soccer field with an IT background dealing with a person who wants more than anything to stay on that field and play. What if the player is bad with names or dates, what if their eyes normally look like Marty Feldman?

    If I get clear direction and authority that if I ask specific questions and get wrong answers the player leaves the game (like the clear direction on bleeding) then I am perfectly OK doing so as it removes at least some of the gray. As it is now it is murky at best and asking me to make these decisions opens me up to additional liability and with no direction we will be inconsistent from game to game, referee to referee.
  14. uniqueconstraint

    uniqueconstraint Member

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    I understand the hesitancy here to get into the "head-examining" business further, I guess I look at it as what's the worst case?

    I'd rather be barred from an assignment for taking a player out unnecessarily than leaving them in with something that could have a severe outcome.

    In my experience, coaches by and large have been great partners in this regard - and the ones that won't partner with you on this should get a nice write-up in your report.

    Others can speak better to this but I think as long as it's a USSF-sanctioned match then their umbrella liability insurance would help.

    If I get sued for taking a player out of the game "unnecessarily" then I'm heading to the TV stations and internet and starting a legal fund.

    EDIT: I can see where camconcay is coming from and this is where I would hope working with the coaches comes into play. Right now it does seem vague at points because the experts and lawyers are still working it out, there's risk all around on this one.
  15. Bubba Atlanta

    Bubba Atlanta Member+

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    I don't think many of us are worried about getting sued for not letting someone play. It's the opposite, and at some point the err-to-the-point-of-stupidity-on-the-side-of-caution mentality can creep in. (Cf. the nearby thread on not sending a get well card to a player for fear of encouraging litigation. Not saying that's stupid, mind you, just sayin'...)

    Simply put, this should not be the referee's decision.
  16. DWickham

    DWickham Member

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    Law 5 empowers and FIFA's Instruction and Guidance (like the USSF ATR) requires that referee "must ensure an injured player is safely removed from the field of play." The power to remove a player is not limited to blood.

    Concussion rules that are being adopted in many states, and already exist in MLS, college (NCAA) and high school (NFHS) address when the player may return to play (and who decides).

    Recent studies have confirmed what the tragic experience of a few major athletes revealed. Concussion presents a serious threat to the player's safety. IMO, understanding the signs and symptoms of someone suffering a concussion or head injury is a part of the official's job - - just like knowing when to deal with lightning, darkness, heat or other threats to the players safety.
    Law5 repped this.
  17. camconcay

    camconcay Member

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    Understood - the issue here is if they are injured. If we think they are but they insist they are not then we do not have the authority to remove them as I see it under USSF.

    This is what I think I was trying to say in regard to concussions. I can see blood or a broken bone and if a player says they are hurt then removal is easy. When they say they are not and they are good to go (think like they take a kicked ball to the stomach, stings, maybe wind knocked out - in a minute they are OK and continue) - how do I know there isn't a more serious injury? If they take the same kicked ball to their face/head, say they are OK, and "seem" to be OK - what authority do I have to say otherwise? Better yet, if they do not "seem" to be OK but insist they are, what authority do I have to declare them injured and remove them?
  18. NW Referee

    NW Referee Member

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    As a referee you have a responsiblity to keep the players safe. Sometimes we over think things but ultimately common sense applies. If a player exhibits concussion symptoms and their coach wants to send the player back in, you should not let them return to play.

    As noted by DWhickham, there are a number of sports organizations and an increasing number of states that have policies on concussions for youth athletes.

    You say that you are "...not a trained medical professional." and then you say "...whenever there is a moderate head injury..." which indicates you have already made a determination about the severity of an injury. I point this out not to be sarcastic but to reinforce that as a referee we do make a decision on injuries.

    The focus on concussions in sports extends from youth sports such as soccer and football to professional sports from the NFL to NASCAR.
    nicklaino repped this.
  19. Bubba Atlanta

    Bubba Atlanta Member+

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    If we have the duty (and with duty necessarily goes authority) to say no in this situation, then we have the exposure to get sued for getting it wrong. That's the point of the NYT article I posted upthread - insurance rates will ultimately go up as a result. Will they go up so much that programs start throwing in the towel - much as you no longer see swing sets, slides, etc. on children's playgrounds (if you see playgrounds at all)? Remains to be seen...
  20. iron81

    iron81 Member+

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    If they don't seem ok, you call the coach over and they have to leave the field. Then you simply deny permission to return. The LotG only say the injured player needs your permission to return, it doesn't say you have to give it.

    We had a thread earlier where Cliveworshipper said FIFA put out a paper that a referee may deny re-entry to a player who he feels was concussed until a doctor gives the green light, though I couldn't find that paper. MassachusettsRef pointed out that you would have game management problems if you denied entry to a player who the coach felt was ok. If you're not planning to allow the player to return, you should certainly inform the coach.
  21. fairplayforlife

    fairplayforlife Member

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    Just stop the game every time they come on the field for an "injury" and point to that person. That is the same thing we are told to do in NFHS. Play the revolving door game until they get the hint. If they want to make an issue of it, screw them, you don't have to say what you think is injured or how.

    Or tell them to write out themselves, a contract, which you approve, stating that they certify the player is safe to play with regard to their health and that they the coach are taking responsibility of liability. Again make sure they write it and in their own words. Personally written and signed contracts go further in court.

    If they aren't comfortable doing that then clearly they aren't comfortable with the player's health to begin with.
  22. Law5

    Law5 Member+

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    I think we're getting a little wired here. As others have noted, Law 5 says that the referee:
    "stops the match if, in his opinion, a player is seriously injured and ensures that he is removed from the field of play....."

    If I believe that a player is suffering from a concussion, layman or not, and I know a lot more about this subject than I ever wanted to know, I'm still the referee and the Laws of the Game make it clear that it is the referee who makes the decision whether a player is seriously injured. I will see that they are removed from the field of play, whether after the injury or whether they attempt to enter the field while still seriously injured.

    As I've stated elsewhere, I have never seen a game report in which the referee reported that the coach/player tried to return to the game after suffering a potential concussion. NEVER. I find myself a bit put off by the attitude that some have expressed that amounts to "Referees can be counted on to always do the right thing, but coaches are pretty suspect." Get off your high horse! At the same time, you need to recognize that, depending on the state in which the game takes place, a certified athletic trainer may be considered qualified to determine if the player actually has suffered a concussion, because you, Mr. Referee, are not qualified to make that medical diagnosis, just to report your observations. (Tim, I'm not talking about you, of course.)
  23. camconcay

    camconcay Member

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    Again not to argue but to hopefully continue discussing this, be careful drawing up contracts or anything else - as far as relieving liability or anything else if it comes to that it is up to real lawyers and the courts (lord forbid) and a document between a soccer coach and a soccer referee written on a soccer field may not hold up.

    I was only hoping to get reference to where we have authority to make a player leave for injuries other than bleeding when they say they are not injured. If they say they are not, then anything we do is what we think is the case. Understanding LOTG law 5 gives us a whole lot of latitude here, but making a decision or not making a decision based on what we as individual referees think is an injury (concussion or otherwise) with out bleeding can lead to problems, especially if we decide a player is injured, team loses, and a real doctor in real medical facilities say they are fine.
  24. uniqueconstraint

    uniqueconstraint Member

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    I understand what you're saying, it's a risk to be sure. But as you said, Law 5 gives us quite a bit of latitude.

    Others have said this (ironically, I think it was Law5) but the ref is who needs to be convinced a player is not seriously injured, not the ref who needs to convince the coach.

    That said I've never (I'd capitalize it but don't want to yell) had a coach who, when faced with a real crunch-time decision, kept a seriously injured player in the game once this seriousness was determined in any fashion.

    Perhaps others have and if so I'm sorry, I suppose there but for the grace of God go I.
  25. Bubba Atlanta

    Bubba Atlanta Member+

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    This is all fine in terms of what we all should do in the exercise of common sense and appropriate attention to the safety of players. That should (almost) go without saying.

    But when rules and laws start getting passed that make it the duty of the referee to be trained and qualified and officially charged with the responsibility to make a determination that a player is or is not fit to stay on the field — then I think we're headed down the wrong path.
    HoustonRef repped this.

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