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updated 10/6/2011 2:49:37 PM ET 2011-10-06T18:49:37

One question has become as much a part of football as tackles and touchdowns: When is it safe for an athlete to return to play after a concussion? No matter what the sport, this decision depends on return-to-play guidelines that experts have drawn up to help keep players safe. The following excerpt from “The Concussion Crisis: Anatomy of a Silent Epidemic” tells the inside story behind the development of the very first set of return-to-play guidelines.

On a brisk fall New England morning in 1984, Dr. Robert Cantu could be found hiking up and down the sidelines of the local high school football field, eyes scrunched in concentration and hands stuffed deep inside his jacket pockets for warmth. Each time one of the teams moved the ball downfield, Cantu would stride after the players and reposition himself on the line of scrimmage. As the sideline physician for high school games in and around Concord, Massachusetts, he wanted to stay as close to the players as possible so he wouldn’t miss any potentially serious spine or head injuries.

With a young son already playing Pop Warner football, Cantu had stepped up when town officials came looking for a volunteer to fulfill the state’s mandate that a doctor be present at every high school game. He figured that a neurosurgeon, like himself, would be best prepared to spot and to handle the types of injuries inherent in football. So each Saturday morning, the slim, redheaded physician would pull on his jeans, running shoes, and, depending on how bitingly cold the weather was, a windbreaker or parka and then drive over to monitor that week’s game. Although Cantu always felt a little nervous as he looked out for injuries, he enjoyed watching football, especially from a vantage point so close to the action.

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But on this particular Saturday, Cantu was more worried than usual. As he strode up and down the field, he couldn’t get his mind off an article he’d recently read in a medical journal. That article described the death of an unnamed nineteen-year-old college football player three years earlier following a seemingly minor jolt to the head.

In late October of 1981, Enzo Montemurro, a compact five-foot-eight, 190-pound fullback on Cornell University’s freshman team, took the field at Dartmouth College eager to show the moves that had made him Toronto’s high school MVP. Right from the opening kickoff, Montemurro looked like he was going to have the best game of his young college career, gaining a total of thirty-two yards the first six times he carried the ball. Then, on a routine play where his assignment was to block would-be tacklers from getting to a ball-carrying teammate, Montemurro bumped an opposing player. The contact hadn’t been particularly solid, so everyone was shocked when the college freshman suddenly collapsed on the sideline after walking off the field with no apparent problem. The team physician and trainer immediately raced over to help, but within seconds Montemurro lost consciousness and became completely unresponsive. He was loaded into an ambulance and rushed the quarter of a mile to the Dartmouth hospital.

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The instant Montemurro was wheeled through the emergency room door, Dr. Robert Harbaugh, the neurologist on call that day, recognized that the situation was dire. Montemurro was in a deep coma, and his breathing was so irregular that he had to be put on a ventilator. A quick test suggested that the pressure in his head was dangerously high. Harbaugh promptly paged the hospital’s chief of neurosurgery, Dr. Richard Saunders, who was in the midst of morning rounds. Saunders ordered a CAT scan, which confirmed that there was extensive swelling on the right side of Montemurro’s brain.

As the two doctors conferred over what would be the best course of action, Harbaugh looked down at the young Ivy League athlete lying motionless on the hospital bed and thought, “This is a person who has his whole life ahead of him—we’ve got to do something.” Saunders told him that the only hope was to remove a section of Montemurro’s skull to relieve the pressure on the brain. Saunders wasn’t optimistic about Montemurro’s chances, but he agreed that they should do everything possible to try to save the teen’s life. Although the operation successfully relieved the pressure on Montemurro’s brain, it didn’t improve his condition. Four days later his family decided it was time to disconnect the ventilator, and Enzo Montemurro died.

Saunders and Harbaugh were haunted by the heartbreaking tragedy of an athlete inexplicably dying young. At the very least, they needed to be able to explain how such a minor jolt on the playing field could have killed a fit, healthy teen so quickly. While waiting for the autopsy report, they began to ask Montemurro’s family, teammates, and coaches about the weeks leading up to the fateful game.

Teammates told Saunders and Harbaugh that Montemurro had been punched in the head during a fistfight four days before the game. He had briefly lost consciousness and went to the Cornell infirmary the next morning complaining of headaches and nausea. Doctors there told him that he had sustained a concussion and should avoid any contact sports until his symptoms resolved. The day before the Dartmouth game, Montemurro asked for medical clearance to play, insisting that his headaches had all but disappeared.

These new details brought to mind a report Saunders had read a few years earlier describing the case of a college football player who died suddenly after a minor hit during a game. The eminent neurosurgeon who wrote the report suggested that that death might have been related to a concussion the player had sustained in an earlier game.

When Montemurro’s autopsy results came in, it was clear there had been microscopic damage to his brain that predated the Dartmouth game by several days. That got Saunders thinking about an animal study he’d read years earlier. The study showed that once a certain pressure in the brain was reached, an irreversible sequence of events was triggered that eventually killed the animal. Saunders reasoned that the fistfight had raised the pressure in Montemurro’s brain to a dangerous but not fatal level and that the minor jolt during the game had pushed the pressure beyond the point of no return.

The more Saunders and Harbaugh thought about the case, the more they realized its grave implications for all the young athletes playing America’s most popular sport. You didn’t need a big hit to kill a kid—a series of minor jolts could add up to a catastrophe. Saunders and Harbaugh wrote up their findings to warn doctors across the nation about this unrecognized threat. Wanting to reach the broadest possible audience, they submitted their paper to one of America’s most prestigious medical journals. The two-page article, published in the Journal of the American Medical Association in 1984, introduced a syndrome that Saunders and Harbaugh dubbed “second impact.”

The warning was clear: second-impact syndrome could occur any time an athlete suffered a jolt to the head too close on the heels of an earlier concussion. If the brain didn’t have enough time to recover from the initial concussion, a second one could have a much more devastating impact—even when the second resulted from nothing more than a light tap. That second hit could cause the brain to swell catastrophically. But it was the first hit, Saunders and Harbaugh discovered, that had made the player into a walking time bomb.

Saunders and Harbaugh’s little paper had a big impact on doctors like Robert Cantu. As he walked the sidelines, Cantu realized that if he missed a concussion today, some kid might get bumped next week and die.

Cantu wasn’t worried just about the kids playing right in front of him. He was thinking about all the kids playing across the nation. He knew that precious few states required sideline physicians as Massachusetts did; few required even an athletic trainer at games. Cantu figured the best way to protect kids from second-impact syndrome was to draw up a set of guidelines that could help coaches and medical personnel figure out when and for how long a concussed player should be sidelined.

At the time, there was no real science to guide him. There weren’t studies to show how long it took concussed athletes to recover; there wasn’t even a consensus among experts on the definition of a concussion. Cantu could only draw on his more than twenty years of clinical experience diagnosing and treating concussions, not just in athletes injured on the playing field but also in patients who came to his office after falls, car crashes, and other accidents. What he came up with was a set of guidelines linking the severity of concussions to the length of time a player should be sidelined. An athlete with a “moderate concussion,” for example, could return to play one week after symptoms had completely dissipated, whereas a “severe concussion” would sideline a player for at least a month.

When Cantu’s guidelines were published in the October 1986 issue of The Physician and Sports Medicine, there was finally a reference for people trying to manage concussions. While Cantu was the first to admit that his choice of suggested recovery periods was “pure seat of the pants,” he figured that they would at least make the point that concussions were serious business and that players often needed to be sidelined.

Moreover, the very existence of a published set of guidelines would send the message that doctors might be able to prevent deaths from second-impact syndrome. Just in case his fellow physicians weren’t as scared as he was by the specter of a second-impact death occurring on their watch, Cantu reminded them that lawyers also read journal articles like his. The clear implication was that malpractice lawsuits over poor concussion management were now possible because there was proof that letting a kid come back before his brain had healed could lead to his death. As Cantu traveled the country explaining his guidelines and preaching his gospel that everyone should err on the side of caution, he would drive his point home with his favorite mantra: “When in doubt, sit them out.”

The guidelines had far less impact on the medical community than Cantu had hoped. Kids with significant concussions were still being sent back into the same game in which they’d been injured. Kids who’d been sidelined were returning to play while still symptomatic from concussions suffered weeks earlier. And every parent’s worst nightmare was still occurring: kids were still being killed by concussions.

Parents would be reminded of the danger whenever the tragic story of a schoolboy dying after a minor hit cropped up in the local newspaper. On Long Island, seventeen-year-old Billy Rideout played through a concussion sustained in a 1986 high school game, collapsed two weeks later on the sideline right after another hit, and died three weeks afterward without ever regaining consciousness. In West Texas, seventeen-year-old Gabriel Sanchez suddenly collapsed and died after suffering his second concussion of the 1988 season. In Southern California, seventeen-year-old Freddy Mendoza shrugged off headaches from a concussion that knocked him out of a 1991 game, collapsed after a hit in the following week’s game, and died two days later.

Though it grabbed headlines and hearts whenever it struck, second impact syndrome was nevertheless a relatively rare phenomenon. The CDC documented seventeen deaths from the syndrome between 1992 and 1995, though its report cautioned that this could be an underestimate. All the deaths were in young athletes, mostly teens. That didn’t surprise brain injury experts because immature brains were known to be more vulnerable to concussions in general.

Although second-impact syndrome didn’t always kill, it was always devastating. The aftereffects would plague survivors like Brandon Schultz for their entire lives.

Schultz was a high school sophomore in 1993 when a jarring collision in a junior varsity game briefly knocked him unconscious and sent him to the sideline with a headache so bad that he was grimacing and screaming in pain. Although he continued to complain of headaches all week, none of his coaches ever suggested that he see a doctor or get medical clearance before returning to play—a standard practice in his Anacortes, Washington, school district for even the most minor orthopedic injuries, but not for head injuries. Back in action on the defensive line just a week after the concussion, Schultz made a routine tackle on the last play of the first half. Ten minutes later in the team’s halftime huddle, he dropped to the ground convulsing in seizures and lapsed into a coma. He was rushed to the hospital, where doctors discovered that his brain was swelling rapidly and performed the first of four emergency surgeries to reduce pressure on it.

Schultz survived, but with severe brain damage that left the onetime A‑student cognitively impaired, partially blind, and physically disabled. With no hope of ever living independently, he was transferred to a longterm-care facility in California. Schultz’s family sued the school district on his behalf for neglecting to institute a concussion policy. In a landmark settlement in 1998, five years almost to the day after his life-altering concussion, the school district agreed to pay for the medical care and rehab services Schultz would need for the rest of his life—an estimated $12.6 million.

Despite its catastrophic consequences, second-impact syndrome was easy for athletes to rationalize away: they figured it was so rare that they were more likely to be run over by a car than struck by second-impact syndrome. A far more prevalent problem would be harder to dismiss. It was becoming increasingly clear that repeated hits to the head could lead to lasting symptoms even when concussions came months or years apart. And if you were among the millions watching America’s most popular spectator sport on any given Sunday, it was impossible to miss this phenomenon.

"The Concussion Crisis: Anatomy of a Silent Epidemic" is available at amazon.com.

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