Like many of you, I grew up with football. I would cheer and applaud the big hits. In high school, college and especially the pros, people worried about broken bones and joint injuries. With helmets, we rarely worried about head injuries.

Over the last several years, however, there’s been increasing evidence to show the dramatic unrecognized effects of head trauma. There has been talk for a while, but this past weekend the NFL called for investigations into head injuries and is looking at changing some of the rules. This week the league decided to start fining players $50,000 to $75,000 for flagrant hits. Because so many players lead with their helmet, there have been proposals to either remove the facemask or eliminate helmets all together. 

Traditionally players, coaches, and parents have thought helmets were protective devices. In fact, most people believe that if you wear a helmet, the chance of a head injury is very small. Unfortunately, that does not seem to be the case. Studies of NFL players have shown that the head trauma they experience is leading to chronic headaches, memory loss, paranoia, depression, premature Alzheimer’s disease and significant brain damage. Retired NFL football players reportedly have three times the rate of depression and 19 times the rate of premature Alzheimer’s (age 30 to 49 years) compared to the general population.

Many people also believe that if they don’t lose consciousness they are OK. It turns out that players who were never evaluated for a “concussion” also demonstrated significant problems. Any violent shaking of the brain can injure certain cells that are linked to learning and memory. A person who suffers a concussion is four times more likely to suffer a second one, and it takes less of a blow to suffer a second injury. Recovery time is very important. Repeated head trauma is therefore a huge risk. What is alarming is that one study reported that high school football players averaged 1,800 hits to the head during practices and games in a single season. 

Head injuries are not limited to football. Boxer Muhammad Ali is a visual reminder of what can happen. Actress Natasha Richardson died in Canada in 2009 from a bleed in her head after a skiing accident in Canada. Other sports, particularly soccer, are also bringing a tremendous amount of attention and calls for stricter rules and even protective gear. There is controversy in soccer as to whether limited blows such as heading the ball can cause brain damage. Many teams have instituted rules limiting practice of heading the ball. All patients, but particularly older patients, may undergo minor falls that can cause significant head injuries. 

So now you have a head injury. What do you do? 

Some athletes are evaluated on the field by a medical professional. Many athletes are transported to the local emergency department. Every fall, we see several athletes each weekend arriving from the athletic fields.

Typically, the patient is examined by an emergency physician and based on history and physical exam, the patient may undergo a CT scan to look for a bleed inside the head. The CT scanner is a frequently misunderstood device. Many people falsely believe that if the CT scan is normal, there is no problem. The CT scanner is very accurate for diagnosing acute bleeding from a subdural or epidural hematoma that requires neurosurgery. It is not very good at diagnosing brain injuries. That diagnosis often requires detailed neurological exams and advanced studies, such as an MRI, that are not available from the emergency department.

Indiscriminate use of the CT scan is also not without risk. The risk of cancer from undergoing a CT scan can range from 1 in 11,080 to 1 in 260, depending on the age and amount of radiation received. Children’s brains are more susceptible to radiation and a study from the British Medical Journal reported that the radiation from a CT scan may cause a decrease in mental acuity. 

Fortunately, Queen of the Valley Medical Center recently purchased an advanced CT scanner, which is currently being installed. The CT scanner has increased acuity and less radiation than the previous scanner. This will allow for both more accurate and less dangerous CT scans.

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When should an athlete return to play?

There is tremendous controversy and no definite right answer. A study by the Center for Injury Research and Policy in Ohio reported that 40.5 percent of high school athletes who suffer a concussion return to play before it was generally considered safe to do so. As I previously mentioned, there is research that indicates that the brain cells recover slowly and make them more susceptible to “second impact syndrome.” Almost all of the deaths that occurred from head injuries in high school had a history of a recent concussion.

If you do suffer any significant head trauma, you certainly want to be more careful to avoid any second blow. If you feel you or your child has had a significant injury to the head, make sure they get checked out as soon as possible. Do not rush the return to play decision. When in doubt, get checked out by a medical professional.

The take-home message is to be careful and limit head trauma whenever possible. Remember to wear your helmet whether playing football, skateboarding, snowboarding, skiing, or riding your bicycle. Try to minimize any repeated impacts.

Paul Kivela, M.D., is an emergency physician at the Queen of the Valley Medical Center in Napa. E-mail him at drkivela@medicallysound.com.

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