The past week has been a tragic one in high school football. Within seven days, three players died -- two after collision injuries, a third untouched during warm-ups. The proximity of these deaths and the common thread of football raise questions for some people about the sport's safety.
To better understand whether such fears are justified, I spoke with Dr. Jonathan Drezner, professor of family medicine at the University of Washington, and Seattle Seahawks team physician. Drezner is an internationally recognized expert in sudden cardiac death in athletes.
Q: What are we to make of these deaths: Do they portend a trend or simply represent a random occurrence?
A: Three in a week is a tragic week. We never want to hear about the death of a young athlete from any cause. But when you look at the overall track record in high school football over many years, there are probably only a handful of traumatic head injuries resulting in sudden death per year among the hundreds of thousands of high school athletes who participate in the sport. Football and other contact or collision sports do carry some risk. We do our best to minimize all potential risk for catastrophic injury, but unfortunately, that risk is still not zero. Some individuals may also harbor conditions that we can't detect or can't screen for that may increase their risk of having a catastrophic event after suffering a traumatic blow.
Q: Is an aneurysm one of those conditions that may present an increased risk (one of the three athletes who died, Demario Harris, had a ruptured aneurysm, according to a report on AL.com)?
A: Yes. If someone has a brain aneurysm -- essentially a dilation of one of the arteries in the brain -- a traumatic blow would put that aneurysm at higher risk of bleeding or tearing, which could lead to severe hemorrhaging and sudden death.
Q: If a young athlete is known to have an aneurysm, would he be advised against participating in a contact sport?
A: If an athlete has a known brain aneurysm, he would likely be advised against participating in a contact or collision sport, under the consultation of a neurosurgeon. Most individuals with aneurysms are asymptomatic. Occasionally, some individuals may have warning symptoms where the aneurysm leaks or bleeds a little bit, causing a sudden onset of severe headache, often described as the worst headache of your life. Those cases are usually evaluated in the emergency room with neuroimaging such as a CT scan which identify the bleed and find the aneurysm.
But most athletes who have aneurysms have no warning signs or symptoms, no neurologic signs or symptoms, and they may be engaged in activities that put them at risk. That risk may be playing football, but it could also be activities like riding a bike or snowboarding.
Q: Is this something we should be routinely screening for in athletes who want to engage in contact/collision sports?
A: No. Aneurysms are a tragic but uncommon cause of sudden death, and the screening technique is not simple or readily available. Even in collegiate and professional realms where there are increased resources compared to youth and high school football, there is no routine neuroimaging or screening for aneurysms. The procedure of choice to evaluate a suspected aneurysm is a CT angiogram which is problematic because a) it is expensive b) it includes a risk of exposure to iodine-based dye (which can cause an allergic reaction in some) and c) it exposes the brain to radiation which may not be good for young brains. I don't think screening for brain aneurysms is feasible or should be pursued.
Q: In the absence of an underlying condition, is a healthy young athlete more at risk for a brain bleed following a blow to the head than an adult?
A: That's a hard question to answer. It's hard to recall a recent case of a college or NFL player with a head injury resulting in a brain bleed that led to sudden death. Even though there are many more times the number of athletes in the high school setting, the fact that there are some cases versus virtually none at the college and professional level may suggest there is an increased risk in this population. But I wonder if the increased risk is not simply age-related but rather that the people who have anatomic disorders that put them at risk are manifesting that risk at a younger age, like high school.
Q: What is the role of helmets?
A: Helmets can certainly reduce the risk of skull fractures; they do not completely reduce the risk of intracranial injury. Forces from blows to the head are still transmitted inside the skull to brain tissues and blood vessels, which is why we still see concussions and vascular injuries. Well-fitting and well-maintained helmets are important to help absorb and dissipate whatever shock and forces that it can in the best way possible. They should not slide on the head, rotate or pop off during play, but unfortunately helmets cannot prevent all of these injuries.
Q: Based on early media reports, it appears that two of this week's high school deaths are related to brain bleeds subsequent to a traumatic blow, but in the third instance, the athlete reportedly collapsed during warm-ups before practice. Without knowing the specific details of the case, does this suggest a different mechanism?
A: Anytime you have an athlete who has experienced no head trauma, who collapses and is unconscious, you have to assume cardiac arrest because sudden cardiac arrest is the leading killer of young athletes on the playing field. When you look at sudden death in high school football, head injuries and intracranial pathology are not the leading cause: heart problems are. The incidence of SCA falls in the range of one in 50,000 to 80,000 high school athletes per year. In fact, there have already been over a dozen instances of death due to SCA in this school year (August and September). Unfortunately, we see a blip at this time of year for sudden death because schools are reconvening, athletes are starting to train again, and exercise is often a trigger in someone with an underlying problem.
Q: What is the current state of screening in high school athletes for cardiac risk?
A: Most athletes are required to undergo a pre-participation physical exam. These are supposed to be guided by standards for history-taking that include a comprehensive symptom history and family history along with a focused cardiac physical exam. It is unclear though how effective screening by history and physical is to identify kids at risk since most athletes who suffer SCA don't have any warning symptoms. Some key things we should not miss are a history of passing out during exercise, unexplained seizures or a family history of sudden cardiac death at a young age (younger than 50).
Q: What strategies exist for improving survival following a sudden cardiac event or a traumatic head injury?
A: First and foremost, high schools need to be prepared to respond. Emergency plans for SCA should be a universal standard. Defibrillators should always be available within three minutes of any sporting activity. Additionally, high schools in the United States hosting an organized practice or a basketball or football game should have defibrillators immediately available (since these are the sports where the majority of these incidents occur). The survival rate for a high school athlete with SCA who receives immediate emergency care -- CPR and early defibrillation -- is in the 80 to 90 percent range. It is indisputable that for kids who do suffer SCA, we have an effective management strategy assuming the cardiac arrest is recognized promptly and that there are personnel trained in CPR and a defibrillator available.
High schools that sponsor football should have an emergency plan in place for what is considered a severe head or neck injury. They should have a spine board on the sideline. They should have an ambulance on-site at games. They should have practiced their emergency response to a player who's down, how to assess signs and symptoms of a severe head or neck injury, how to roll the athlete onto the spine board and load the athlete into the ambulance. There should be a plan as to where the ambulance is going in terms of the local trauma center that has neurosurgical care.
The planning elements for cardiac, head and neck events should all be part of a high school's comprehensive plan for an athlete with a significant injury.
Q: How are we tracking the frequency of these types of injuries and the associated outcomes?
A: The National Center for Catastrophic Sports Injury Research has been doing this for some time. [Since the 1980s, there has been no pattern related to the number of annual football-related deaths, according to the center.] Recently, the center has partnered with other institutions that have similar expertise and interest. There is now a consortium with three divisions focusing on different areas. The University of Washington represents the Division of Cardiac Injury in Sport (where Drezner is the director). The University of Connecticut represents the Division of Exertional Injury in Sport, directed by Dr. Doug Casa. The University of North Carolina, where NCCSIR is based, represents the Division of Traumatic Injury in Sport, directed by Dr. Kevin Guskiewicz. The goal of the center is to keep the best record possible of these cases.
The NCAA now has a mandatory reporting system for catastrophic injury in athletes (initiated Aug. 1 of this year) which will roll through the NCCSIR, so this center should ultimately have the best data, but it may take some time to acquire. All sudden death and near-fatalities (for example, a case of SCA where the individual survives) are included in the reporting. We need to include near-fatalities in the reporting system to understand the true magnitude of the problem.
One of the biggest challenges to understanding the incidence of these events is you can only keep track of what you hear about. If the athlete gets injured and there's no media report, we may never hear about some of these cases. In the college setting, shockingly, only about 50 percent of cases of sudden death have a media report that goes with them. At the high school level, it's going to be significantly less.
Q: How do you counsel parents who ask: "Is it safe for my kid to play football?"
A: This is a really hard question and a very individual question. There are so many benefits to playing team sports: health benefits of exercise, values of teamwork and work ethic. But the athletes and their families have to accept they're playing a collision sport that has some low, but inherent, risk.
It may be a random occurrence that these three young athletes all died in the same week. It is certainly a tragedy for them, their families and their communities, but it may ultimately raise awareness of some issues that are very difficult to grasp. Planning for emergency management should absolutely be a part of every high school's plan, including having certified athletic trainers on the sideline, having defibrillators available and practicing emergency response in advance. It should be noted, however, that even in the optimal setting, with all the proper resources and an appropriate and timely medical response, the result can still, unfortunately, be death. The hope is that those instances can be minimized by putting some of these measures in place.