Roughly one-fourth of Clairton High's male students take the field on any given football game day, which is saying something at a school with the seventh-smallest enrollment in the Western Pennsylvania Interscholastic Athletic League.
And, at Heinz Field Saturday, Clairton won its fourth Class A championship in the past five Novembers, with a woman watching its players' backs.
Tammy Ridgley is the Bears' certified athletic trainer.
They needed her, too. Star quarterback Desimon Green and two starting linemen exited the semifinals a week earlier with injuries, but Green -- despite leg cramps -- accounted for both Bears scores and the linemen played in a 12-0, championship victory over Rochester.
"We're cool," she said, a smile and her curly, blonde hair visible under a wool cap pulled low. " I want to see the kids get back as fast as they can, but I want them to be back safe."
She and Clairton demonstrate the heightened health concern surrounding Western Pennsylvania football in particular and scholastic sports in general. At a time when the number of concussions diagnosed is spiking, at a time when a lagging economy causes budgetary cutbacks, local school districts continue to spend $30,000 or more per year for a certified athletic trainer -- and some retain two, three, even four. To school administrators, it's an investment to protect the brains and bodies of their students and athletes.
Every one of the WPIAL's 115 public high schools plus all nine City League teams contracts with or directly employs at least one certified athletic trainer. That's far ahead of the national curve -- the average across America is barely half.
"The old story is, 'We can't afford to have one,' " said Mike Cordas, parroting some school districts' explanations. He is a Harrisburg-area physician and chairman of the sports-medicine advisory committee to the Pennsylvania Interscholastic Athletic Association. "You can't afford not to have one. That is your first line of defense."
"There are 7.6 million kids playing high school sports in this country, and now less than 50 percent of those high schools have a certified athletic trainer on staff," said Dawn Comstock, the principal investigator at the Center for Injury Research and Policy in Columbus, Ohio. Another survey last summer by the Scripps-Howard News Service placed the figure at nearly two of every three school districts nationally without such full-time help. Dr. Comstock added, "I think we're letting those kids down."
The trainer's job
The certified athletic trainer is integral in the discovery and management of a concussion, as well as all other injuries. First, the trainer may be an eyewitness to the injury or at least the triage provider. If a serious traumatic brain injury can be ruled out, the trainer begins standard concussion care: He or she determines symptoms such as memory loss and headaches from observation and answers provided by the injured athlete; removes the athlete from practice or a game; acts as the intermediary among parents, coaches, medical providers and school officials; supplies over-the-counter pain medication as necessary; and arranges transport to an emergency room or a concussion specialist.
Finally, once a concussion is formally diagnosed, the certified athletic trainer implements any prescribed management plan and -- when cleared by a physician -- oversees the athlete's return to play. This all makes the trainer the gatekeeper to the field or court.
"We had a lot more diagnosed this year, which is a good thing," said Mark Jones, athletic director at Leechburg High, the sixth-smallest public school in the WPIAL.
"It's a good busy. A positive busy. A positive trend. I think we are quickly changing a mind-set," said Larry Cooper, the Penn-Trafford High athletic trainer. He appreciates the greater concern because he serves as a committee member and/or chairman for various groups, from the WPIAL sports-medicine advisory panel to the Pennsylvania and national athletic trainers associations. "Things have definitely improved -- for the student-athlete, for the coaches and for me, too. The parents don't realize how much better it is. There are people here providing quality health care for their student-athlete."
West Allegheny High athletic director Dave McBain has been a certified athletic trainer for a quarter-century. In football's heyday in Western Pennsylvania, he said, the team's trainer could have been a science teacher because he understood the medical Latinate and was deft enough with his hands to adequately tape the players.
They've come a long way from smelling salts.
Mr. McBain notes that the American Medical Association's national policy adopted in 1998 recommends a certified trainer be present at athletic events. Just four weeks ago, the American Academy of Neurology released its 2010 recommendations for concussion treatment and management, and it included this finding: A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussions.
"The athletic trainer is the most important [medical professional] on that field," continued Dr. Cordas, who also worked with Penn State football in years past. "He or she knows that athlete better than any physician; he or she sees them every day. The athletes confide in him or her; they trust them. The athletic trainer is the most indispensable part of the outfit."
WPIAL and PIAA rules have been on the books so long that they require only that the host athletic director be able to telephone an ambulance within five minutes or so -- a stipulation set long before the age of cell phones. New rules do, however, focus on recognizing and managing concussions.
The WPIAL planned to staff Saturday's championships in the four football classifications with a certified athletic trainer, an ambulance and crew, plus physicians.
For the most part, though, health care is left to each school district.
Most across Pennsylvania arrange for an ambulance and/or team doctor to be at each football home game and many home events in other sports.
The bottom line: You never know when an injury might happen -- in particular, a concussion.
"I couldn't live sensibly without" a certified athletic trainer, Leechburg's Mr. Jones said. "You have to have that care right here, right now."
"I feel parents should be demanding that their kids have access" to a certified athletic trainer or someone else educated in sports medicine, said Dr. Comstock. "I don't want a coach to be making these decisions for my nephew."
New laws around the country -- and one such bill is stalled in the Pennsylvania Senate after passing the House in September -- mandate that coaches in high school and often youth sports receive education about concussions and take an active role in removing players from practices and games when they show concussion symptoms.
No legislation mandates the presence of a certified athletic trainer.
Pennsylvania is one of only four states that requires certification of an athletic trainer but not licensure, as happens in 39 states. To fall in line with most of the nation and to join this state's other licensed medical professionals with four-year degrees or more, the Pennsylvania Athletic Trainers Society seeks to get Pennsylvania to someday license them, too, said group president Greg Janik.
About 70 percent of the state's school districts retain the services of a certified athletic trainer, he said. "Granted, I'd like it to be 100 percent." A certified athletic trainer must pass an accredited program taught at only 20 colleges in Pennsylvania (of more than 200) and approximately 350 across America. Almost three of every four certified athletic trainers hold a master's degree.
"Nothing against [emergency medical technicians]. They do a great job," said Mr. Janik, an associate clinical professor and the head athletic trainer at King's College in Wilkes-Barre. But they are not trained to make assessments, diagnoses and/or determine return to play; certified athletic trainers are. I've spoken to school boards about why they should have a certified athletic trainer vs. an EMT. To have someone there not only for games but for practices -- and the majority of injuries occur at practices," he said. Trainers not only provide medical care, but strength and conditioning training, nutrition advice, counseling, and, should there be an injury, the ability to implement a rehabilitation program.
Moreover, it's illegal in Pennsylvania for an EMT or paramedic to work as an athletic trainer without proper certification.
"What we pride ourselves in is our certified athletic trainer is sort of like a primary-care physician," said Craig Castor, the supervisor in sports medicine at Allegheny General, where he oversees contracts with 12 local high schools to provide such help.
Eric Cardwell is one of those certified athletic trainers. He has spent the past 11 years at North Hills High. His 6-foot-3, football-sized frame and bald head make him a recognizable presence on the football sideline. He and another AGH-contracted athletic trainer, Missy Bauer, have spent more than 20 years combined with North Hills High and Middle School athletes. As he put it, "I've known these kids since seventh grade."
AGH-contracted trainers may well find themselves using the same tool founded at and operated by UPMC: Immediate Post-Concussion Assessment and Cognitive Testing, or ImPACT. In the end, however, it is just that: a tool. The certified athletic trainer relies upon his familiarity with the athlete, his observation and his hospital-system resources.
"If you recognize the injury whenever the accident occurs, that's half the battle right there," said Mark Lovell, director of UPMC Sports Medicine's concussion program. Mr. Cardwell often sends suspected concussion sufferers to AGH's Dr. Edward Snell, while UMPC's certified athletic trainers under contract at their 44 local high schools and seven colleges refer athletes to Dr. Lovell and others.
The cell phone has become another vital tool. At West Allegheny High, UPMC-contracted certified athletic trainer Matt Triebsch shuttles from varsity football practice to an eighth-grade football game, with his cell ready in case another coach in another sport needs him. Said Mr. McBain, that school's athletic director: "You have to determine what's the most hazardous activity of the day."
"Even if you have four athletic trainers," said Dave Tumbas, director of UPMC athletic training, "there can be six events going on at once.
"We're far beyond the person standing there with a towel and a water bottle."