Examining high school safety guidelines and how they're regulated

The tragic death of Tom Cutinella, the Shoreham-Wading River football player who passed away after an on-field injury Wednesday, sparked interest across Long Island about what the safety guidelines for high school sports are and how they are regulated.

An average of 12 high school and college football players die each year from football-related accidents, according to a recent study in the American Journal of Sports Medicine. About 1 million boys play high school football.

Cutinella's official cause of death has not been given, but police and school officials believe it's the result of a head injury.

"In New York State, we really take a lot of precaution in making our athletes safe,'' said Lawrence High School athletic director Pat Pizzarelli, who also serves as football coordinator for Nassau County public high schools. "Unfortunately, a young man lost his life and we're all sad and upset about it. It was the worst nightmare possible. There is an inherent risk in participating in athletics on any level.''

It is recommended that a physician be present for all football games, according to the New York State Public High Schools Athletic Association's handbook. If the services of a physician cannot be obtained, others qualified to give emergency care such as physician assistants, emergency squads or athletic trainers should provide coverage, the handbook says.

Pizzarelli said he believes student-athletes in New York State are as safe as they possibly can be.

"Some states don't mandate anyone qualified at all at games. They have no one there,'' Pizzarelli said. "Also, all our coaches are certified in first aid and CPR.''

What's more, NYPHSAA initiated the Concussion Management and Awareness Act in July 2012 and required all public and charter schools to comply, beginning with the 2012-13 school year. The mandate requires coaches, physical education teachers, nurses and athletic trainers to complete an approved course on concussion management and sets standards for the care of athletes who have suffered even minor brain trauma.

One way to make high school athletics safer is for each school to have its own certified athletic trainer, Pizzarelli said. Several schools on Long Island do not have athletic trainers.

Having an on-site ambulance at football games increases the margin of safety, Pizzarelli said.

Michael Wulforst, an athletic trainer who works with high school teams, agreed.

"In case of a catastrophic situation, knowing that it's right there provides comfort,'' Wulforst said. "It's an immediate response to a situation. There's no time delay.''

There is no requirement for an ambulance to be at a football game for any athletic activity, although many schools on Long Island choose to have one.

"It's up to the local individual school district,'' said Don Webster, the executive director of Section XI, the governing body of interscholastic high school sports in Suffolk County. "They'll set up what they feel is their emergency care from there.''

Pizzarelli recommends that all athletic directors ask their local fire departments to come to football games.

Said Pizzarelli, "Whether or not they will is a town-by-town situation.''

Evaluating injuries

Pizzarelli became Lawrence's athletic director 24 years ago. In his second year, he said, he asked for an athletic trainer and has felt better about his student-athletes' safety ever since.

"I feel so much more at ease,'' Pizzarelli said. "I think every school should have one. But every district decides for themselves what's best . . . But I just think it's so much better.''

Many schools cite budgetary reasons for not having an athletic trainer. Athletic trainers typically earn a salary of $35,000 to $75,000 per year, according to the U.S. Bureau of Labor Statistics.

"It does cost money,'' Pizzarelli said. "We've made recommendations to try to get New York State to mandate it in high schools. It hasn't got that far yet. Maybe this tragedy will help that. Maybe some good will come out of this."

NYSPHSAA executive director Robert Zayas could not be reached for comment.

Wulforst has worked as Sachem North's athletic trainer since 1995. He said his familiarity with students at the school allows for better communication and a higher level of comfort. He added that the better he knows a student-athlete, the better he's able to detect how serious an injury might be.

When an athlete suffers an injury while playing, a "primary'' evaluation is used to see if the injury is life-threatening. Trainers use the "ABCs'' of CPR -- check airways, breathing and circulation -- to determine if the athlete is conscious.

If that checks out OK, a trainer then tends to the specific area of the body that is causing pain. If the situation dictates, the athlete is removed from the field for a more detailed "secondary'' evaluation that consists of more tests or exercises. Based on those results, a decision is made whether and when to allow the athlete to return to action.

Concussions -- the second-most-common injury in high school sports (behind sprains), according to a 2013-14 study by the University of Colorado at Denver -- are tricky to identify because the symptoms are not visible.

Dr. Philip Schrank, an orthopedic surgeon who is on the sideline for football games at Sachem East and Ward Melville, said he uses a series of tests to determine if an athlete might have a concussion.

Schrank has athletes look up at the sun to see how sensitive they are to light, tests their sensitivity to sound by clapping his hands and judging their response, and asks them to perform "Serial 7s,'' in which an athlete starts at 100 and subtracts seven until reaching zero.

"We also check balance and other cognitive skills, and there are more ominous signs like a complaining of numbness,'' Schrank said. "But it's the invisible injury.''

ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the most widely used and most scientifically validated computerized concussion evaluation system. There are 39 schools in Suffolk, according to Ray Nelson, the sports medicine outreach coordinator for Orthopedic Associates of Long Island in East Setauket, that use ImPACT.

Sachem North's football players are ImPACT tested, Wulforst said.

"It's a baseline test that we gather on them so that should we suspect an issue along the lines of a concussion, we can go back and compare them to their baseline," Wulforst said. "It that allows for comparative analysis."

In the event that a trainer discovers that an athlete is not breathing during the "primary" evaluation, 911 is called and the school refers to its own emergency action plan, Wulforst said.