1. Concussion Management for the Referee: Strategies for Safety Tim Ehrsam NISOA National Referee USSF National Referee Emeritus tim.ehrsam@oracle.com

2. February 2011 Tim Ehrsam - CSOA Disclaimer The information in this presentation has not been sanctioned by VISOA, NISOA, NCAA, or any other governing body Some of this information was presented at the 2010 Oklahoma NISOA National Referee Program and VISOA Referee Recertification Camps The information in this presentation is designed to provide awareness of possible strategies to help soccer officials deal with concussion incidents

3. February 2011 Tim Ehrsam - CSOA Concussion: What is It? A traumatic brain injury (TBI) that interferes with normal brain function with or without losing consciousness Results from a direct blow to the head, or force transferred to the head, that slams the brain into the skull Symptoms include loss of consciousness, headache, dizziness, confusion, nausea, or balance problems

4. February 2011 Tim Ehrsam - CSOA Concussions: What’s the Issue? Point of Emphasis in Prior Years –2008-09 – “Advocated that a concussed athlete be removed from play and not allowed to return to play on that same day.” –2009-10 - Unconscious Player - “If the player is determined to be unconscious or apparently unconscious by game officials, the player cannot return to the game until written authorization by a physician is presented.” Potential for Serious Injury Retaliation – Modern airborne elbow warfare All sports, all sanctioning bodies

5. February 2011 Tim Ehrsam - CSOA Concussions: What’s the Issue? Less than 10 percent of concussions result in loss of consciousness ~10 percent of Student-Athletes in contact sports will have concussions this season Females are more likely than males Concussion is the most common athletic injury

6. February 2011 Tim Ehrsam - CSOA Concussions: What’s the Issue? Concussions are Serious –Student-Athletes who have had one concussion are more susceptible to another, increasing their risks if they return prematurely –Second Impact Syndrome – suffering another concussion before the prior TBI has healed completely can result in swelling of the brain, which can be fatal

7. February 2011 Tim Ehrsam - CSOA 2010-11 NFHS Concussion Rules 3-3-1c3 (Substitutions) Expanded Points of Emphasis (p.69) Suggested Guidelines for Management of Concussions (Appendix B, p. 107 & www.nfhs.org) www.nfhs.org Points of Emphasis

8. February 2011 Tim Ehrsam - CSOA 2010-11 NFHS Soccer Rule 3-3-1-1c3 Any player who exhibits signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, nausea, or balance problems) shall not return to play until cleared by an appropriate health-care professional. (Please see NFHS Suggested Guidelines for Management of Concussion). Note that it’s not merely “loss of consciousness”

9. February 2011 Tim Ehrsam - CSOA Play Rulings: 3.3.2 Situation F Players A2 and B2 hit heads in attempting to head the ball and both are injured. In the opinion of the referee, player A2 was unconscious for a short period of time. RULING: Player A2 shall be immediately removed from the contest and shall not return to play until cleared by an appropriate health-care professional.

10. February 2011 Tim Ehrsam - CSOA Points of Emphasis If the player is determined to be unconscious by the trainer, the player CANNOT RETURN without a Doctor’s written permission. Note that it assigns responsibility to the trainer

11. February 2011 Tim Ehrsam - CSOA Suggested Guidelines for Management of Concussion Definition of concussion Common Symptoms Suggested Concussion Management –No return to play that day –Evaluation that day –Medical clearance prior to returning –Follow-up & return to play protocol

12. February 2011 Tim Ehrsam - CSOA Points of Emphasis – Handling Concussions Concussions are of increasing concern and need to be dealt with immediately. If a player may be injured due to any type of blow to head, STOP THE GAME IMMEDIATELY, and get the trainer on the field. Only let the player back into the game, if the player is cleared by the trainer. Make sure that THE TRAINER PERSONNALLY VERIFIES THE PLAYERS ABILITY TO RETURN TO THE GAME TO THE REFEREE TEAM. IF THE TRAINER SAYS THE PLAYER MAY HAVE SUFFERED A CONCUSSION THEN THEY CANNOT PLAY W/O DOCTOR’S PERMISSION. Note – Schools are required to have a concussion management policy which sets forth conditions for handling concussions and assigns responsibility on what school officials have the authority to clear a player suspected of a possible concussion to return to play during that match.

13. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions During Play Pre-game Post-game

14. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions - Pre-game Review the Rules At site, identify the Athletic Trainer (AT) and review appropriate Concussion Management Plan Referees and Trainer agree on a process for dealing with concussion situations

15. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions – During Play - Recognition What to look for: –Elbows/blows to the head –Athlete “goes limp” –Eyes closed and apparently can’t open them –Incoherent speech, blank stare –Unresponsive to voice commands, questions or statements –Poor coordination and “out of sync” –Unresponsive to tactile stimulation (don’t do this yourself!)

16. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions – During Play - Recognition Memory Loss - Player doesn’t remember: –Name, teammate name, team name –Why he/she is here or where “here” is –Injury or action preceding it –Why game being played –Score of game –Who scored –Who is winning

17. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions – During Play - Procedure Referee –Quick assessment if needed –Stop Play/Clock –Beckon AT onto field –Describe incident to AT as needed (they may not have witnessed it) AR/4 th –Get referee and/or AT attention All – Maintain awareness of other activity (players, bench, etc.)

18. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions – During Play - Procedure Referee –Discuss possible misconduct with AR/4 th –Confirm restart and location –Confirm injured player identity & time with AR/4 th AR/4 th –Confirm with AT whether this was a concussion incident, if possible –Ensure scorer is aware of player and re-entry approval procedure –Scorer to inform AR/4 th if player attempts re-entry –Permit substitutes as appropriate All – Maintain composure and focus Before Restart of Play:

19. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions – During Play - Procedure AR/4 th –Confirm with AT whether this was a concussion incident –Confirm player has been cleared by team physician or designee according to concussion management plan –Permit/deny re-entry as appropriate –Inform referee as needed Referee –Confirm / Deal with permit/deny re-entry situation if needed Player Re-entry after Restart of Play:

20. February 2011 Tim Ehrsam - CSOA How to Deal with Concussions – Post-Game Game Report –Reconfirm injured player and incident info on game report (see POE) –Note “concussion incident” for that injury –If conflict, note AT/Physician name and contact Pete (e.g., you saw player lose consciousness, but AT permitted player to re-enter/play)

21. February 2011 Tim Ehrsam - CSOA Final Thoughts Awareness of head trauma incidents increasing It is a serious issue Have a plan, discuss with all participants, and execute the plan The trainer is your friend When in doubt, err on safety