Nathan Stiles' parents had little reason to doubt their 17-year-old son was ready to return to the football field after suffering an apparent concussion at the homecoming game. He spent weeks resting, and a doctor gave him the all clear to play again. Even a CT scan that usually detects more serious head injuries came back negative, his mother said.
The Spring Hill High School senior died in late October, a day after collapsing on the sidelines at a game. A county coroner determined this week that the running back and linebacker died of a rare but severe brain injury that likely occurred during the earlier game but went undetected.
The suburban Kansas City school district says it followed new rules designed to reduce concussion risks. But in an era of heightened awareness about player safety and head injuries, family, school and medical experts are left wondering if anything more could have been done to prevent his death.
"It's tragic," said Rick Bowden, assistant executive director of the Kansas State High School Activities Association. "But I don't know if anything could have been done differently. When a doctor releases a student to return to participate, what more can we ask?"
Football organizations at every level from the youth Pop Warner leagues to the National Football Association are tightening the rules and procedures in an effort to prevent head injuries. Players are routinely fined for dangerous tackles in the NFL, and high school coaches are urged to keep players off the field when a head injury is suspected.
Effective this fall, any high school player who shows signs, symptoms or behaviors associated with a concussion must be removed from the game and cannot return until cleared by an appropriate health care professional. The concussion rule was approved by the National Federation of State High School Associations and adopted in Kansas and elsewhere.
On Oct. 28, Stiles scored at least one touchdown in Spring Hills' 99-72 win over Osawatomie. But then he left the field on his own after hitting his head on the ground while being tackled by two opponents late in the second-quarter. He collapsed, and a day later he died.
"I think he just hit the ground pretty hard with his head," Spring Hill coach Anthony Orrick told the Osawatomie Graphic newspaper. "He came on the sideline and told one of my assistants, 'my head is really hurting.'"
The Johnson County coroner on Thursday ruled that Stiles died of a subdural hematoma, or bleeding between the tissue layers connecting the brain and skull. Medical experts say it's unclear why the CT scan done after the initial injury on Oct. 1 didn't show the bleeding.
The warning signs of concussions — headaches, confusion, and a loss consciousness, among others — are similar to the physical changes that would trigger concern over more serious brain trauma, said Dr. Mark Halstead of Washington University in St. Louis, co-author of an American Academy of Pediatrics study on concussions.
"Everything we educate people about concussions is about looking for the more serious injury," he said. "I would expect to see (a subdural hematoma) fairy soon on a CT scan, not pop up hours later."
Such traumatic injuries in contact sports are not new — but they are uncommon especially as helmets and other equipment used during contact sports have improved.
A 2007 study in the American Journal of Sports Medicine identified more than 80 brain injury-related fatalities reported at the high school and college levels between 1965 and 1969. But from 1989 through 2002, that number decreased to just eight deaths, largely due to improvements in the safety and design of helmets.
Subdural hematomas can be deadly. Eighty-six percent of the deaths from brain injury in sports over a more than 50-year period through 1999 were due to subdural hematomas, researchers found. And in nearly 60 percent of the catastrophic football injuries, players reported a prior head injury — the scenario in the Stiles case.
A complete copy of the coroner's findings will not be available for several weeks, pending completion of toxicology reports. Michael Handler, the deputy Johnson County coroner who revealed his findings on Thursday, was traveling Friday and could not be reached for comment.
Some Kansas lawmakers suggested they may hold legislative hearings to determine whether school officials have sufficient medical knowledge and training to make the proper decisions about head injuries in athletics. A volunteer doctor was on the sidelines the night Stiles collapsed.
"Probably, we should review the policies for when kids can go back to play after head injuries," Senate Education Committee Chairwoman Jean Schodorf said.
Spring Hill superintendent Bart Goering said Stiles' death "reinforces the critical nature of sports-related student injuries" and stressed in a statement that the district looks forward to medical recommendations that will make students safer. In their own statement, Stiles' family said Friday that the coroner's report reaffirmed their belief that all reasonable measures were taken to prevent the tragedy.
"Just as Nathan's life and faith have touched many, we are equally hopeful that any medical findings can be useful in the continuing effort to prevent and treat head injuries in all sports," the family's statement said.
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Zagier reported from Columbia, Mo. Associated Press writer John Hanna in Topeka, Kan. contributed to this report.