An ongoing series that explores how Oklahoma’s severe human-needs issues affect the lives of children.

At least nine student athletes in Putnam City Public Schools suffered a concussion playing sports last school year.

More than a dozen sustained one in Norman Public Schools.

In Tulsa Public Schools, 38 students suffered a concussion in the 2016-2017 school year, with the district reporting 13 more in the first six weeks of this year. Edmond Public Schools’ three high schools recorded 62 concussions.

Across the state, hundreds, if not thousands, of student athletes each year sustain a concussion, a type of traumatic brain injury caused by a blow to the head that shakes the brain inside the skull. By one Tulsa researcher’s count, an average of one to three students receive a concussion at every Oklahoma high school every week.

A concussion can have long-lasting effects and can be fatal, which is why Oklahoma law requires a child with a suspected concussion to be pulled from the game or practice immediately.

That call should be made by an athletic trainer, a licensed medical professional trained to identify, treat and prevent potentially catastrophic conditions like brain injuries, several health organizations said. But about three in four schools in Oklahoma don’t have one.

“The only way to appropriately protect these kids is to make sure they have qualified medical staff on the sideline, and that would be an athletic trainer,” said Ron Walker, associate dean at the University of Tulsa’s Oxley College of Health Sciences.

All sports carry a risk of injury, some more than others. Sports also provide many benefits, teaching children about teamwork, winning and losing, and healthy lifestyles. Many parents agree the benefits outweigh the risk and want to make the games safer rather than see them disappear.

Many high schools with no athletic trainer are small ones in rural Oklahoma. But even larger districts are going without. Oklahoma City Public Schools, which has thousands of students participating in sports, hired full-time athletic trainers just this year, made possible by a three-year grant from the National Football League.

Across the state, the lack of athletic trainers in schools means concussions go undiagnosed, untreated and untracked.

What State Law Requires

Schools aren’t required to track the number of concussions occurring among students, and most don’t, unless they have an athletic trainer on staff. Oklahoma City Public Schools, for instance, didn’t collect data on student head injuries in 2016-17; the district didn’t have a full-time athletic trainer that year. But this year, they have athletic trainers, who reported treating 14 concussions in football players.

Oklahoma’s concussion law requires a student or youth-league player with a suspected concussion to be pulled from the game or practice. They aren’t allowed to return until they get written clearance from a medical professional. Coaches and other staff also must watch a 20-minute training video each year.

Student athletes and their parents also must sign an annual form acknowledging they understand the risks of a concussion.

Walker, who advocated for that law as well as a 2016 update extending the law to youth recreational teams and private schools, surveyed athletic trainers at 18 Oklahoma high schools for an entire school year to measure concussions.

The average was more than one per week in the fall, and three per week in the spring, for every high school.

A national survey in 2015-2016 estimated 342,497 concussions in high school athletes across the country. If that total were allocated by state per capita, it would translate into several thousand in Oklahoma. The study is conducted annually by the Colorado School of Public Health.

Sometimes, the injury can have long-lasting effects. In 2016, a Holdenville High School football player suffered a head injury during a game and required surgery and was hospitalized for months. Last month, a running back at  Union High School in Tulsa suffered a traumatic brain injury and underwent surgery, the district disclosed on Friday.

Sometimes, injuries can be fatal. Since 1982, 185 high school student athletes nationally have died from causes tied to their sport.  Of those, 126 were playing football.

One was Oklahoma’s Ben Hamm.

Death of a Player

In September 2015, Hamm, a junior linebacker for Wesleyan Christian School in Bartlesville, made what appeared to be a routine tackle on a kickoff return, got up unsteadily, groaned and went to the ground. He was taken by ambulance to St. Francis Hospital in Tulsa, where he died more than a week later.

Ben Hamm, who was a junior running back for Wesleyan Christian School in Bartlesville, died after a routine tackle during a game in September 2015. Credit: Provided by Steven Hamm

“I watched that game over and over and over again. He was having the game of his life. He was making tackle after tackle, and he had just scored a touchdown,” Steve Hamm, the boy’s father, said. “Then he just dropped like a rock to the ground.”

At the funeral for Hamm, superintendent Rocky Clark made a vow to the boy’s parents: “We will put in measures to ensure that something like this does not happen again.”

One of the first things Clark did was hire an athletic trainer. The trainer is present during all football games through a partnership with Oklahoma Wesleyan University. Having a trainer there brings peace of mind, Clark says.

Ben had previously suffered a concussion during his freshman year, and didn’t play football the rest of the season. His parents warned him: another concussion, and you’re done playing football for good, said Steven Hamm.

A scare as a sophomore sent Ben back to the neurologist, but the doctor said it wasn’t a concussion, so his parents agreed he could keep playing.

Wesleyan Christian has an ambulance service present at every game — a safety measure above what is required by the state. But the small school’s experience demonstrates some of the haphazard safety measures in place in schools without an athletic trainer.

Pleas for medical assistance might come during a game over the loudspeaker, as the crowd hears, “Is there anybody here who’s a doctor?” Clark said.

Or the team may arrive at an opponent’s school and be handed directions to the nearest hospital, often 30 or 45 minutes away.

“Just about any small school can get involved (in football), even ones that don’t have much of a budget … for things that might provide some safety measures,” Clark said.

Advocates say student athletes need more comprehensive care, not just at games, and not just for football.

In high school sports, football had the highest number of life-threatening injuries of all kinds, followed by female cheerleading, baseball, wrestling, and track and field, according to a report by the National Center for Catastrophic Sport Injury Research.

Although lately attention has been on concussion risks in football, soccer players receive nearly as many concussions, according to Colorado School of Public Health researchers.

Many concussions occur outside of competition. According to that report, head injuries, including concussions, were the most common injury both in games and practice for all sports combined, accounting for 28 percent of game injuries and 20 percent of practice injuries.

Walker, the TU researcher, surveyed 18 Oklahoma high schools in 2014-2015 and found 80 percent of injuries were happening during practice, with 20 percent at games.

He also looked at which sport was producing the most concussions. In the fall, football accounted for three times as many as all other sports combined. In the spring, concussions were highest in soccer and an “other” category that includes cheerleading and off-season football.

A Dearth of Athletic Trainers

The Korey Stringer Institute at the University of Connecticut tracks the location of high school athletic trainers as part of its Athletic Training Location and Services, or ATLAS, project. Its state-level maps are based on a study conducted from 2012 to 2015 and voluntary reporting by schools since 2015.  While Oklahoma’s map doesn’t reflect the current status of all schools, it shows the continued scarcity of athletic trainers in large areas of the state.

How Oklahoma Stacks Up

Most states do better than Oklahoma in providing athletic trainers. From 2011 to 2013, just 26 percent of Oklahoma schools had an athletic trainer, compared to a U.S. average of 70 percent, according to a 2015 study published in the Journal of Athletic Training. Connecticut, Washington, D.C., Hawaii and a few other states had athletic trainers at or near 100 percent of schools. Only Alaska had a smaller percentage of schools with trainers than Oklahoma.

In a ranking of states’ health and safety policies designed to prevent catastrophic injuries among student athletes, Oklahoma comes in at No. 37, the Korey Stringer Institute at the University of Connecticut reports.

“If you’re choosing to offer sports as an educational program, you have a duty to help ensure these students don’t sustain life-altering medical conditions or even death,” Walker said.

In 2008, the Oklahoma State Board of Health supported a resolution to make athletic trainers available to all high schools. The resolution cited at least eight deaths since 1999.

Four Oklahoma City district high schools received athletic trainers this year, funded by a grant from the NFL and Mercy Hospital. The league committed $35,000 over three years to each school, and Oklahoma is one of four states to be selected. Mercy is funding the rest of the trainers’ salaries.

Keith Sinor, the district’s athletic director, said he’s been pushing the district to hire full-time trainers for six years; previously, the district contracted with trainers only for games.

“They’re starting to show the value of the trainer, and hopefully the schools will be able to pick up and fund it going forward,” Sinor said.

Referring to low-income students who have no primary doctor, he added, “With our kids, if they get hurt, that’s probably the only person they’re going to go see.”

Other schools receiving the NFL grant include Millwood, Duncan and Tulsa high schools. Tulsa Public Schools has two full-time trainers, one funded by the district and one from outside sources, and seven part-time trainers funded by the NFL.

Glencoe Public Schools, with just 340 students, is one of the smallest schools in Oklahoma with a full-time trainer. High School Principal Chad Speer said they just got lucky. Their trainer, Joanna Crow, is his sister-in-law, and she was recruited because she teaches special education. Glencoe offers various sports, but not football.

Before, looking out for players’ injuries was his job; he is not just the principal, he’s a coach (and a bus driver, and a science teacher). Hiring an athletic trainer was far down the list of needs.

“We need teachers, we need bus drivers, we need janitors, we need aides,” Speer said. “There’s just so many other things that we need first.”

Collin Gentry, Mercyhealth athletic trainer, checks sports medicine supplies before football practice at Northwest Classen High School in Oklahoma City. Credit: Jennifer Palmer / Oklahoma Watch

A Trainer’s Role

Athletic trainers act as a neutral voice on the sidelines, without a stake in the outcome of the game, trained to recognize signs of concussion and make the call to remove a player.

Concussion Signs and Risks

Concussions can be difficult to identify. Confusion, dizziness, vomiting and a headache can be signs of a concussion, but not all players have those signs.

Studies suggest a player should rest their brain for 24 to 48 hours after a concussion, meaning students likely can’t attend class, do homework or take exams. Kids with a concussion can be slow to return to school and their grades can suffer.

“People are starting to understand that a concussion is a whole-person injury,” said Darren Lunow, president of the Oklahoma Athletic Trainers’ Association. “It’s not like a broken arm or a sprained ankle … You’re talking about the sensory and motor control center for the entire body.”

New research is recognizing the compounded danger of cumulative head trauma, or repeated concussions. Many times, when a player dies, they had symptoms or a previous concussion prior to their death, according to the National Center for Catastrophic Sport Injury Research.

Awareness of the risks of concussion have received heightened attention recently due to research studies and  the number of retired professional football players who have sued the NFL.

A Boston University study published last month found that playing tackle football under the age of 12 can lead to head blows that heighten the risk of short- and long-term neurological impairments.

Athletes with a concussion are more likely to be diagnosed in schools with an athletic trainer and less likely to be returned to play prematurely, according to an American Academy of Pediatrics study.

Not every state requires athletic trainers to be licensed, but Oklahoma does. There are more than 400 active licensees, and they are overseen by the state Medical Board.

Schools without athletic trainers rely on coaches, who typically aren’t medical professionals and whose job ultimately is to teach the sport and win games.

Many kids, typically, won’t prioritize their health over the game.

“These are teenage boys,” said Walker, who’s also a part-time athletic trainer at Sequoyah High School in Claremore. “They don’t think about, ‘Hey, what about when I’m 25?’ … They think about Friday night.”

Student athletes also can feel pressure to keep playing.

Concussion risks are one of several reasons for a drop in high school football enrollment nationwide, reported the Washington Post. Many states, especially in the Midwest and Northeast, have fewer football teams now than five years ago, but Oklahoma is an outlier with 31 new teams during that time frame. Only the District of Columbia gained more.

“There’s always inherent risks in a collision injury,” Lunlow said, “but I think there’s many things that can be done — athletic trainers being at the top of that list — where you can make your game safer.”

‘Ben Would Not Want That’

After Ben Hamm’s death, none of the Wesleyan Christian players wanted to quit, and more students wanted to join the football team and play in his memory, said Clark, the superintendent. Clark wrestled with ending the program, but was encouraged to keep it going by Ben’s dad. In fact, this year the school started a middle-school football program.

“I knew some people would say ‘We don’t need football, our kids will get killed,’” Steven Hamm said. “And I said, ‘Ben would not want that.’”

Rather than turn away from football, Steven Hamm became even more active with the team. He would be on the sidelines at games, looking out for players after a hard hit, checking for disorientation and other concussion symptoms. His wife, Misti, however, won’t go to any games, or watch them on TV.

“I believe in the game,” he said, “and I think there’s a lot more safety things that we need to do … to make the game safer.”

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