The Bells Are Ringing

“Jared, have I told you that when I played football in high school we wore leather helmets?” Of course I had. For decades I have been telling boys just starting their football careers that I had been a “leatherhead.” Jared is a junior, so I'm sure he'd heard my story at least a couple of times. But he's a nice kid and simply shrugged his strapping shoulders, and looked down at his six-pack abs.

Mostly, I tell the anecdote to watch expression on their parents' faces. The kids already assume I am older than dirt. But I enjoy watching their folks struggle to do a bit of quick math to figure out my age.

In the 1960s plastic football helmets were in regular use, but my high school coach was wise beyond his years and realized that their canvas strap suspension systems similar to those for a construction hard hat were inferior to the 1-inch- to 1½-inch–thick all-leather helmets, which were more absorbent. So Coach passed the plastic headgear down to the scrubs and ordered what must have been one of the last production runs of leather helmets for the varsity.

The equipment wasn't the only thing antique about my football career. By the time I was in college, I had on more than a couple of occasions stood in a huddle next to a teammate who was too fog headed from a hit on the previous play to know his assignment on our simplest running play. If he wobbled to the bench, the odds were high that he would be back in the huddle later in the game.

When I became the new doc on the block, I inherited the job of team physician to a pitifully underperforming high school football team. In that role I know that I sent more than a dozen young men with concussions back into action. Despite clearly having had their bell rung, if they knew who they were, who the opponent was, and had a general sense of the score, they could play. If they failed to meet those skimpy criteria, I sat them out and made sure I talked to their parents to be sure they would be watched closely at home that evening. There was never any discussion of limiting their activity for the next week.

Nowadays, concussion is a hot topic at all levels of sport. And while I tend to be an old school kind of guy, this new emphasis is clearly a change for the good. Maybe the biggest step has been the acceptance by physicians, coaches, players, and parents that loss of consciousness is no longer a requirement for the diagnosis. Maybe it never was for some, but the prevailing notion was “no loss of consciousness, no worry.” The second revelation has been that it's the subsequent concussions that are usually the most damaging.

Media coverage of the cautious and patient management of concussion in high-profile athletes has made it much easier for me to recommend the same approach for my patients … and for them to accept it. When high-paid professionals – tough guys by reputation – are willing to sit out big games until their symptoms clear, the wimp factor evaporates.

Many emergency room physicians still seem to be relying less on good histories and exams and instead ordering needless and potentially dangerous head CTs.

While protocols vary, the ones that I have seen seldom call for imaging studies in a patient with a normal exam and a reliable family.

Preseason baseline testing has become standard in our school department, but postconcussion management continues to remain an area with fuzzy edges. Athletes can have reasons for a headache other than a lingering concussion. Even uninjured teenagers can be drifty by nature. But that's never going to change. This old leatherhead has learned some new tricks and is going to err on the side of sitting out the concussed athlete until the fog is a distant memory.

“Jared, have I told you that when I played football in high school we wore leather helmets?” Of course I had. For decades I have been telling boys just starting their football careers that I had been a “leatherhead.” Jared is a junior, so I'm sure he'd heard my story at least a couple of times. But he's a nice kid and simply shrugged his strapping shoulders, and looked down at his six-pack abs.

Mostly, I tell the anecdote to watch expression on their parents' faces. The kids already assume I am older than dirt. But I enjoy watching their folks struggle to do a bit of quick math to figure out my age.

In the 1960s plastic football helmets were in regular use, but my high school coach was wise beyond his years and realized that their canvas strap suspension systems similar to those for a construction hard hat were inferior to the 1-inch- to 1½-inch–thick all-leather helmets, which were more absorbent. So Coach passed the plastic headgear down to the scrubs and ordered what must have been one of the last production runs of leather helmets for the varsity.

The equipment wasn't the only thing antique about my football career. By the time I was in college, I had on more than a couple of occasions stood in a huddle next to a teammate who was too fog headed from a hit on the previous play to know his assignment on our simplest running play. If he wobbled to the bench, the odds were high that he would be back in the huddle later in the game.

When I became the new doc on the block, I inherited the job of team physician to a pitifully underperforming high school football team. In that role I know that I sent more than a dozen young men with concussions back into action. Despite clearly having had their bell rung, if they knew who they were, who the opponent was, and had a general sense of the score, they could play. If they failed to meet those skimpy criteria, I sat them out and made sure I talked to their parents to be sure they would be watched closely at home that evening. There was never any discussion of limiting their activity for the next week.

Nowadays, concussion is a hot topic at all levels of sport. And while I tend to be an old school kind of guy, this new emphasis is clearly a change for the good. Maybe the biggest step has been the acceptance by physicians, coaches, players, and parents that loss of consciousness is no longer a requirement for the diagnosis. Maybe it never was for some, but the prevailing notion was “no loss of consciousness, no worry.” The second revelation has been that it's the subsequent concussions that are usually the most damaging.

Media coverage of the cautious and patient management of concussion in high-profile athletes has made it much easier for me to recommend the same approach for my patients … and for them to accept it. When high-paid professionals – tough guys by reputation – are willing to sit out big games until their symptoms clear, the wimp factor evaporates.

Many emergency room physicians still seem to be relying less on good histories and exams and instead ordering needless and potentially dangerous head CTs.

While protocols vary, the ones that I have seen seldom call for imaging studies in a patient with a normal exam and a reliable family.

Preseason baseline testing has become standard in our school department, but postconcussion management continues to remain an area with fuzzy edges. Athletes can have reasons for a headache other than a lingering concussion. Even uninjured teenagers can be drifty by nature. But that's never going to change. This old leatherhead has learned some new tricks and is going to err on the side of sitting out the concussed athlete until the fog is a distant memory.

“Jared, have I told you that when I played football in high school we wore leather helmets?” Of course I had. For decades I have been telling boys just starting their football careers that I had been a “leatherhead.” Jared is a junior, so I'm sure he'd heard my story at least a couple of times. But he's a nice kid and simply shrugged his strapping shoulders, and looked down at his six-pack abs.

Mostly, I tell the anecdote to watch expression on their parents' faces. The kids already assume I am older than dirt. But I enjoy watching their folks struggle to do a bit of quick math to figure out my age.

In the 1960s plastic football helmets were in regular use, but my high school coach was wise beyond his years and realized that their canvas strap suspension systems similar to those for a construction hard hat were inferior to the 1-inch- to 1½-inch–thick all-leather helmets, which were more absorbent. So Coach passed the plastic headgear down to the scrubs and ordered what must have been one of the last production runs of leather helmets for the varsity.

The equipment wasn't the only thing antique about my football career. By the time I was in college, I had on more than a couple of occasions stood in a huddle next to a teammate who was too fog headed from a hit on the previous play to know his assignment on our simplest running play. If he wobbled to the bench, the odds were high that he would be back in the huddle later in the game.

When I became the new doc on the block, I inherited the job of team physician to a pitifully underperforming high school football team. In that role I know that I sent more than a dozen young men with concussions back into action. Despite clearly having had their bell rung, if they knew who they were, who the opponent was, and had a general sense of the score, they could play. If they failed to meet those skimpy criteria, I sat them out and made sure I talked to their parents to be sure they would be watched closely at home that evening. There was never any discussion of limiting their activity for the next week.

Nowadays, concussion is a hot topic at all levels of sport. And while I tend to be an old school kind of guy, this new emphasis is clearly a change for the good. Maybe the biggest step has been the acceptance by physicians, coaches, players, and parents that loss of consciousness is no longer a requirement for the diagnosis. Maybe it never was for some, but the prevailing notion was “no loss of consciousness, no worry.” The second revelation has been that it's the subsequent concussions that are usually the most damaging.

Media coverage of the cautious and patient management of concussion in high-profile athletes has made it much easier for me to recommend the same approach for my patients … and for them to accept it. When high-paid professionals – tough guys by reputation – are willing to sit out big games until their symptoms clear, the wimp factor evaporates.

Many emergency room physicians still seem to be relying less on good histories and exams and instead ordering needless and potentially dangerous head CTs.

While protocols vary, the ones that I have seen seldom call for imaging studies in a patient with a normal exam and a reliable family.

Preseason baseline testing has become standard in our school department, but postconcussion management continues to remain an area with fuzzy edges. Athletes can have reasons for a headache other than a lingering concussion. Even uninjured teenagers can be drifty by nature. But that's never going to change. This old leatherhead has learned some new tricks and is going to err on the side of sitting out the concussed athlete until the fog is a distant memory.