Hey, who's that fat guy down there? Those seven words were all Darin Eklund needed to hear to become concerned.
As a student athletic trainer at Oregon State University in the mid-1990s, Eklund saw his share of concussion-type injuries. They weren't always easy to diagnose - often times they aren't - but in one sentence he had all the answers he needed.
It was crude. It was insensitive. And it was totally out of character.
DFJ photo by Tracy Runneberg
After suffering two concussions, should Jenn Willems have played softball for Northeast Hamilton in 2012 and 2013? The former Trojet answers honestly.
"The worst concussion I ever saw was a women's soccer player," Eklund, a physician's assistant at Webster City Medical Clinic since 1998, said. "The girl went to do a slide tackle, the other girl went to jump over and the girl sliding took a knee to the head. We got her over to the bench and she looked down the sideline and said, 'hey, who's that fat guy down there?' We didn't say anything and a few minutes later she again said, 'hey, who's that fat guy down there?' Well, it was the coach.
"She had concussion symptoms for over a month."
Unfortunately, not all head trauma injuries are so finite. They're not like broken bones; there is no X-ray that can be taken that shows a concussion. And therein lies part of the predicament that medical professionals encounter when diagnosing concussions.
Concussions: By The Numbers
CDC estimates reveal that 1.6 to 3.8 million concussions occur each year.
5-10 percent of athletes will experience a concussion in any given sport season.
Fewer than 10 percent of sports-related concussions involve a loss of consciousness (eg., blacking out, seeing stars, etc.)
78 percent of concussions occur during games (as opposed to practices).
Some studies suggest that females are twice as likely to sustain a concussion as males.
Headache (85 percent) and dizziness (70-80) are the most commonly reported symptoms immediately following concussions for injured athletes.
Estimated 47 percent of athletes do not report feeling any symptoms after a concussive blow.
The impact speed of a football player tackling: 25 mph.
The impact speed of a soccer ball being headed: 70 mph.
"The problem is I can't do a CAT scan and say this one has a concussion or not. You can't give a blood test and say, 'yes, this one has a concussion,'" Eklund said. "It just doesn't work that way."
That's precisely why, nearly 100 percent of the time, trainers, physician's assistants and doctors are all going to err on the side of caution. Tempting fate with a head injury is simply too risky.
"I would have people come in and say I didn't have a concussion because I wasn't knocked out," Eklund said. "Well, you don't have to be knocked out to have a concussion. Any kind of injury to the head where you come out and are feeling groggy, confused, tired or have a headache, any of those things are a concussion and I'm going to be conservative with them."
BreAnn VanDeer, a licensed athletic trainer for Fort Dodge Senior High, knows exactly what Eklund is talking about. She's seen everything from glancing blows to vicious hits lead to concussions in her three years on the job. She's also quick to put on the brakes.
"If a kid comes to me and says I don't feel right and my head hurts, more than likely I'm going to have them go through the protocol just in case," she said. "The talk of concussions is so high right now and these kids are 14 to 18 years old. There's no point in risking further injury.
"Some concussions are completely obvious ... they're knocked out and not moving, that's going to be a concussion. But some of the kids that are completely blacked out, they're sometimes the fastest to recover. Others you don't even see get hit and they can be prolonged for weeks. So, in my mind, it has nothing to do with the hit that they take. Each person heals differently and that's what decides how long they're going to be out."
Coaches Off The Hook
It used to be that coaches were put in the precarious position of also being the onsite doctor, to some degree. Was an athlete hurt or injured? And how injured was too injured to return to competition?
It could be confusing and dangerous.
"A few years ago when you got your bell rung, you shook it off and got back at it," Webster City head wrestling coach Ted Larson said. "It's a whole different deal now ... it's out of my hands. It's not my call on whether an athlete is going to compete again (following a head injury). That's the doctor's call. If someone is diagnosed with a concussion, they don't compete again until they get a release from a (medical professional)."
In April of 2011, the Iowa State Legislature adopted an act concerning the protection of students from concussions and other brain injuries, and the result was the Concussion Management Protocol set forth by the Iowa High School Athletic Association and the Iowa Girls High School Athletic Union.
The protocol states that a series of criteria - a complete physical and cognitive test, a return to normal cognitive daily activities, low-impact aerobics, basic exercise, non-contact training drills and finally full-contact practice - must be met before an athlete can receive medical clearance to return to normal competition.
Medical professionals must take the protocol seriously because, according to Eklund, the worst-case scenario is sending an athlete back into the fray before a head injury has fully healed.
"My biggest concern with concussions is making sure athletes don't go back until their symptoms are completely gone," he said. "Second Impact Syndrome - a second concussion before the first one is healed - is where it really gets dangerous and in some cases it can become fatal. And outside of boxers, Second Impact Syndrome doesn't happen in kids over the age of 20, to our knowledge."
The protocol steps aren't always easy to decipher or complete. Some athletes return to a sense of normalcy quickly, while others spend weeks and sometimes months attempting to complete the process.
"If a patient comes to me with a head injury, I go through the SCAT (Standardized Concussion Assessment Tool) and establish a score," Eklund said. "If they don't do well, they may come back the very next day and take it again and they may come back daily until the score improves."
The generic SCAT - also known as a baseline test - Eklund has adopted includes such things as concentration exercises, and balance and coordination exams. But even this can generate uncertainty because, as Eklund says, he has no way of knowing how athletes would've scored prior to injury.
"In a perfect world we would have every athlete in the school system get a baseline test before the season even started as part of their sports physical, and that's what a lot of schools in the bigger areas are starting to do," he said. "It's good to know where they start from. When I see (athletes) for the first time, I'm seeing progress, but I don't know how much progress because I don't know where they started from."
Webster City Athletics Director Bob Howard spent parts of the past year researching baseline testing and recently pulled the trigger and purchased ImPACT Testing and Computerized Neurocognitive Assessment Tools.
In the upcoming weeks, starting with the fall sports programs, all WCHS athletes in grades 9-12 will undergo the assessment to provide the school with a baseline before the start of competition. Howard says the program cost of $500 was taken from the athletic fund.
"We are going to require every student-athlete, nine through 12, to take the test," Howard said. "All of the football players will be done next week ... the cheerleaders are going to do it, too.
"This will give us a baseline performance. Then if (athletes) do have a concussion, then the doctor will be able to ask us to run another test to compare. But the second time you take it, regardless of the results, your doctor will determine when you meet the protocol."
Howard continued: "To me a lot of the issue in the past has always been kids coming back too soon. This is something that helps determine when they actually meet the protocol of when they can come back."
Dr. Jim Kumm, the owner and operator of North Central Chiropractic in Webster City, will administer the tests.
There's no doubt that establishing a baseline for every athlete prior to the start of the season can be a useful tool. But they do nothing to help prevent concussions.
Can Concussions Be Prevented?
Eklund, VanDeer and Howard can all agree on one basic fact - there's one way and one way only to eliminate all risk of an athlete suffering a concussion.
"The best prevention there is? Don't play sports, but that's certainly not an option for most kids," Eklund said. "I certainly wouldn't tell my kids not to play sports ... if my (kids) wanted to play football, sure, I don't have a problem with it.
"You could be walking down the street, trip and fall and get a concussion."
Basketball players can't play on a bed of feathers. Football players can't be swathed in bubble wrap.
Taking the risk of concussions out of sports simply isn't an option, particularly when it comes to football, which thrives on contact on a play-by-play basis. But that doesn't mean things can't be done to lessen the probability.
Howard, a 36-year veteran and Hall of Fame football coach, has gone to great lengths with his WCHS program to reduce the factors.
"I think you can limit the risk of them a little bit," Howard said. "We've always done everything we can to mitigate the damages or lessen the chances of injuries. When I was at Sigourney-Keota, every one of our kids wore knee braces. The kids hated them, but we had only one knee injury in 27 years."
He's now taking the same approach to head injuries in the Lynx locker room.
WCHS players are outfitted with the latest and greatest protective equipment on a yearly basis. The high-end Riddell helmets the players wear cost as much as $280, and Howard says he purchases approximately 12 new helmets per season to replace outdated models.
Every helmet in the team's arsenal is also professionally checked prior to the start of each season to ensure it meets the proper standards.
The same goes for shoulder pads and other protective gear.
"The kids wear the best helmets and shoulder pads that money can buy," he said. "That was a commitment that we made when I came here ... our shoulder pads are what college teams wear."
Howard and Eklund are both quick to point out the importance of a proper mouth piece as well. Even 10 years ago, many players opted to cut the ends off their mouth pieces in order to communicate better on the field, but as more knowledge on head injuries surfaced it was determined that modifying mouth guards significantly tarnished their effectiveness.
"When I was at Oregon State we had a team dentist and all 80 players got molded and had professional mouth pieces," Eklund said. "Imagine getting hit on the chin and your teeth clack together, particularly your back molars. All that force gets transmitted to the teeth and up to the brain. But put a piece of rubber back there and now you've got that layer of cushioning in between. That's a lot of force that gets absorbed."
Howard has championed the idea of his players visiting their family dentist to get a molded mouth piece.
"Mouth pieces are huge," he said. "I still buy mouth pieces that I give away, but I've got quite a few kids this year going to the dentist and getting theirs made. If not, then I've suggested at least buying the multi-layered mouth pieces for more protection."
Additional strength training, learning proper tackling techniques and even scheduling additional saturation of the practice and game fields are other factors Howard has implemented as well.
"I think strength and conditioning is a big way of lessening your chances of injury," Howard said. "Having neck strength and shoulder strength is kind of like a shock absorber for your head. And I think watering the fields is also a big deal. We'll start watering our practice field for three weeks before we start playing on it and it will be as soft as we can get it. We'll water the game field at least once a week right through the season to keep it soft."
Learning the correct way to deliver hits could be most beneficial, but even then the risks aren't completely eliminated. Football is a fast-paced game with moving parts at all times. Sometimes things just happen.
"We work real hard on teaching technique, things like shoulder blocking and shoulder tackling," Howard said. "Not hitting with your head and not hitting like they hit on television, stuff like that. But people move, that's the nature of the sport. I could have a target on your body, but you don't want to get tackled and you move.
"There is no guarantee. There are no rules you can put in or a way you can completely eliminate them."
It begs the question: If Howard had never been a football coach, knowing what he knows now, would he let his child play?
"I would let my son play if he had no history of concussions," he said. "It's risk and reward. I know that a concussion is a huge, serious deal, but I also know the rewards you get from football can't be got anywhere else. For most 16, 17 or 18 year old boys that aren't doing much physical labor and getting things handed to them, in football, at least here, that's not the way it is. These kids work their butts off and there are a lot of positive rewards."
Deny, Deny, Deny
BreAnn VanDeer has seen it all before; kids hiding from her after an injury, or downplaying the symptoms all in an effort to stay on the playing surface rather than the sidelines.
VanDeer, who is slated to begin her fourth year as an athletic trainer for Fort Dodge Senior High, understands how competitive 16, 17 and 18 year olds can be. They don't want to sit; they want to play, sometimes at the cost of their own health.
It's her job to sift through the half-truths, particularly when it comes to head injuries.
"I've definitely had situations, especially when kids are seniors and think they're going to miss a lot of playing time, where they'll try to hide (injuries)," she said. "Younger players are more likely to come to me right away. They're more hesitant to go back in if they think something is wrong."
Masking or altogether hiding concussion-like symptoms can be a dangerous game in athletics, and the more aware kids are of that fact the better off their health will be in the long run.
"My goal is to make sure that kids understand this isn't just getting your bell rung. This actually has serious ramifications," Eklund said. "The risk of having Second Impact Syndrome is not something to be ignored or laughed at. You have to be very honest with me, with the coaches and with the parents, but also with yourself. It's hard to lie to yourself."
Softball Wins Out
An 'I got caught' smile spreads across Jenn Willems' face as she sweeps her hair out of her eyes while mulling over the question.
It was a straightforward question: Should you have been playing softball?
"I probably should have sat out because I'm going to have my health for the rest of my life," Willems said after a few seconds of silence. "Playing sports, that's something I had for four years in high school, but I'm not going to need those the rest of my life. I need my health."
Now more than a month after the lights have been turned off on her prep athletic career at Northeast Hamilton, Willems admits she wasn't always forthcoming with her medical team.
Her first concussion came on the basketball court on Valentine's Day, 2012, and she was ultimately diagnosed with Post-Concussion Syndrome, meaning she showed symptoms of the concussion for a lengthy period of time.
The headaches and dizziness lasted for roughly two months; at least that's what she told her doctors. In reality, she says they continued throughout her junior season of softball.
"I still had a lot of symptoms, and just putting on the helmet to bat was the worst," she said. "I kept thinking, 'do I tell my coach and ask if I can just play defense?' But I guess I just kind of got used to it."
Still, she stayed silent.
"I knew if I told the doctors they would probably say I wouldn't be able to play, but I think if things had gotten really bad I wouldn't have played," she said.
Concussion No. 2 came later in December of 2012 at a basketball game in Tripoli. And although not as bad, the symptoms lingered longer than she let anyone see.
Five months later, as she got set for her senior season on the softball diamond, she knew she wasn't operating at 100 percent capacity.
"The symptoms kept going on, but I never told anybody and I never had any (doctor's) appointments," she said. "(Pitcher) Molly Greenfield and I have been best friends forever and she knew if I wasn't feeling well and that was good because I was on the field with her all the time. When we'd warm up she'd always ask me if I needed to take a break."
Athletes, particularly adolescents, can trick themselves into believing anything in the heat of battle. But after the crowds have thinned and the uniforms have been placed in storage, they all must look in the mirror and ask themselves one thing: Was it worth it?
"Looking back now I'm glad I got to play softball my senior year because that's always been my favorite sport," Willems said. "It's the one I always looked forward to."
For Willems, thankfully, it did work out. Although she still suffers from occasional headaches, for the most part she's able to live a normal life. She runs most mornings and she's already put the softball glove back on for a family game.
She's yet to garner the courage to enter a pick-up basketball game though, and that may be for the best.
Athletes Need To Know
The Sports Concussion Institute says an individual that suffers through one concussion is one to two times more likely to receive a second one. If they've had two concussions, the risk of a third increases to two to four times more likely; three concussions pushes the odds of a fourth to three to nine times more likely, and so on.
No one is invincible. And the sooner athletes learn and accept that, the better off they'll be in the long run.