HB 15-STUDENT ATHLETE TRAUMATIC BRAIN INJURIES  8:27:11 AM CHAIR DICK announced that the next order of business would be HOUSE BILL NO. 15, "An Act relating to prevention and evaluation of and liability for traumatic brain injuries in student athletes." 8:27:25 AM REPRESENTATIVE PRUITT moved to adopt the proposed committee substitute (CS) for HB 15, Version 27-LS0130\M, Mischel, 2/17/11, as the working draft. REPRESENTATIVE SEATON objected for discussion. 8:27:51 AM REPRESENTATIVE MIKE DOOGAN, Alaska State Legislature, paraphrasing from the sponsor statement, which read [original punctuation provided]: More than 60,000 high school student athletes sustain concussions each year. The number is much greater when you include middle school and younger children. The National Football League has recently begun focusing on concussions and brain trauma, raising public awareness of this serious problem, and many states are now moving to add protections for students who participate in sports or other potentially dangerous activities. While concussions and brain trauma are more prevalent in football, many other sports and activities are also dangerous, with girls' soccer resulting in the second-most concussions. A concussion results from the brain striking the inside of the skull, and can be caused by a blow to the head, or by violent motion of the head. Though the risk can be somewhat reduced with a helmet, it cannot be prevented with external equipment. While it is nearly impossible to completely prevent an initial concussion or brain trauma, this legislation seeks to minimize complications and more permanent conditions that can be caused when athletes continue to practice or play after receiving a concussion. HB 15 is modeled after legislation that recently passed in Washington State, known as the Zackery Lystedt Law. Zackery was a middle-school football player who was returned to a game after suffering a concussion. He sat out for about 15 minutes, and then returned to the game, forcing a game-saving fumble, but suffering a further head injury on the play. The second injury caused a brain hemorrhage that ultimately lead to the removal of both sides of Zackery's cranium, leaving him drifting in and out of a coma for three months. He has battled his way back to some sense of normalcy, but will never fully recover from this avoidable injury. HB 15 simply requires school districts, in consultation with the Alaska School Activities Association, to develop and publish guidelines and information to educate coaches, student athletes and parents about the nature and risks of concussions and traumatic brain injuries. The bill will require that a student athlete suspected of suffering a concussion or brain trauma be removed from practice or play, and not be allowed to return until cleared by a licensed health care professional. While there is no way to completely prevent concussions or traumatic brain injuries, we can strive to prevent the serious complications and potentially life-altering or life-threatening ramifications that can occur from continuing to practice or compete once a brain injury has occurred. This is a critical public health issue, and a responsibility to our children we should take seriously. 8:31:22 AM FRANK AMEDURI, Staff, Representative Mike Doogan, Alaska State Legislature, explained that the two major changes for the committee substitute (CS) were (1) documentation requirements from the Alaska School Activities Association (ASAA) that the training for parents, students, and coaches all be documented in writing that it had been received, and (2) that "a person who is acting at the direction and under the supervision of a licensed physician" was now also defined as a "qualified person" to allow a student to return to play. He added that certified athletic trainers, although not licensed in Alaska, were licensed in 47 other states, and were often the people who would make the decision for a student to return to play. 8:34:34 AM REPRESENTATIVE P. WILSON asked if village health aides, who were not nurses but were supervised by a physician's assistant or an advanced nurse practitioner, were qualified to make this decision. MR. AMEDURI replied that, as long as the supervisor was licensed, the village health aide would be qualified. 8:35:09 AM REPRESENTATIVE P. WILSON asked to have that confirmed. 8:36:39 AM REPRESENTATIVE SEATON withdrew his objection. There being no further objection, Version M was adopted as the working draft. 8:36:48 AM MR. AMEDURI suggested that on page 3, line 3, it be amended to read "licensed health care provider." 8:37:23 AM REPRESENTATIVE SEATON reported that the House Health and Social Services Standing Committee (HSS) had considered that Indian Health Service health professionals were to be exempt from state license. 8:38:27 AM REPRESENTATIVE SEATON moved to adopt Conceptual Amendment 1, as follows: Page 3, line 1, after "licensed health care provider, or" Insert "a health care professional exempt from occupational licensing" There being no objection, it was so ordered. 8:39:05 AM REPRESENTATIVE FEIGE directed attention to page 3, line 12, and asked about the liability if the accident did not occur on school property. 8:39:46 AM MR. AMEDURI replied that he would research an inclusion for events off the school property. 8:40:23 AM REPRESENTATIVE FEIGE, directing attention to page 3, line 12, suggested amending this to include "on, in search, or off school property." 8:40:49 AM REPRESENTATIVE PRUITT offered his belief that line 11 clarified that this addressed a nonprofit youth organization. 8:41:37 AM MR. AMEDURI agreed that the intent was to extend the immunity to contractors who worked for the school district. He offered an example of the baseball season which continued after the end of the high school baseball season. He offered his belief for the intent to be coverage for any school event. 8:42:36 AM REPRESENTATIVE FEIGE asked if it was necessary to mention school property. 8:42:45 AM MR. AMEDURI replied that he would seek clarification. 8:42:57 AM REPRESENTATIVE FEIGE stated the importance for protecting the school districts from liability. 8:43:08 AM REPRESENTATIVE PRUITT offered his belief that page 3, lines 12 and 13, released the school district from liability. 8:43:49 AM MR. AMEDURI noted that these were school related events which were often contracted with outside groups, and that the bill intended to include protection of the contractor from liability. 8:44:39 AM REPRESENTATIVE P. WILSON, reflecting on track students who run through town while training, asked about coverage and liability if one of them were hurt. 8:45:54 AM REPRESENTATIVE SEATON expressed concern that this offered a broad waiver of liability which did not currently exist in law. He suggested that this was beyond the purview of the House Education Standing Committee and that HB 15 should be forwarded to the House Judiciary Standing Committee. 8:47:18 AM MR. AMEDURI, in response to Representative Seaton, said that the liability language was intended to ensure that children were protected through recognition of an injury and through precautions from continued play until they were released by a medical professional. The bill did not release anyone from responsibility if negligence had occurred. 8:49:17 AM CHAIR DICK opened public testimony. 8:49:28 AM KENNETH EDMONDS, Director, National Football League (NFL), reading from a prepared statement, [Included in members' packets] stated that the NFL supported HB 15, and that this will help to "prevent preventable brain injuries and make sports and recreational activities safer for Alaska's youth athletes." He stated that the NFL wanted to put player safety first in all sports, at all levels. He pointed out that the NFL had strict "return to play" guidelines, and that a similar approach was necessary for youth players. He reported that more than 40 percent of high school athletes returned to participation before they were fully recovered. He shared that the NFL promoted state initiatives similar to the Washington State law named after Zackery Lystedt, as previously mentioned. He listed the three core principles: concussion education for parents, coaches, and youth athletes; immediate removal from play or practice of a youth athlete who appeared to have suffered a concussion; mandatory clearance of the youth athlete by a licensed health care provider trained in evaluation and management of concussions. He declared that HB 15 would make youth athletics safer, would ensure the necessary time for healing, and would reinforce that medical decisions by health care professionals would take precedence over the playing decisions of coaches and players. He pointed out that these laws had now been passed in nine states, and were being actively considered in 15-20 other states. 8:53:53 AM REPRESENTATIVE SEATON asked if other states had statutes that required appropriate protective equipment. He asked if prevention of the first concussion was often written in statute. 8:55:01 AM MR. EDMONDS said that it was difficult to prevent the first concussion from occurring, even with proper equipment. He said that HB 15 intended to raise the awareness among school officials, youth athletes, and parents for the dangers of brain injuries, and the heightened risk of a second concussion when there was not adequate time for recovery. 8:57:32 AM The committee took a brief at-ease. 8:58:47 AM CHRISTOPHER DEAN, Certified Athletic Trainer, Alaska Athletic Trainers Association, testified in support of HB 15. He reported that concussions were under reported and considered a non-injury as there were no visible signs of injury. He estimated that 300,000 high schoolers suffered concussions each year, with 25 percent occurring in football. He stated that HB 15 put the responsibility on everyone to intervene on a child's behalf. 9:00:20 AM BRENDA SHELDEN, President, Alaska Athletic Trainers Association, stated the necessity for knowing the signs and symptoms of concussions. She reported that standards already existed to apply to protect student athletes, and she offered support for HB 15. 9:01:42 AM REPRESENTATIVE FEIGE asked what other sports involved a higher risk for concussions. 9:01:55 AM MR. DEAN, in response to Representative Feige, stated that hockey and football had the highest risk, but that basketball, cheerleading, and wrestling also had a high risk for concussion. He said that every sport had the possibility for concussions, and that they were generally under reported, as coaches encouraged students to continue to play. He stressed that concussions were serious injuries. 9:03:02 AM REPRESENTATIVE FEIGE asked to clarify that a concussion was a bruising of the brain. MR. DEAN explained that it was an interruption in the normal function of the brain, and that medicine was not aware of all the mechanism of the injury. He established that most concussions would show no indications on a CT scan or an MRI. 9:03:55 AM REPRESENTATIVE P. WILSON asked about ways to educate for this. 9:04:17 AM MS. SHELDEN reported that an educational program, Heads Up, was available at a nominal cost, and was geared toward the athlete. She said that this program showed incidences, signs and symptoms, and follow up procedures. She stated that athletic directors had to also be educated for the expectations of coaches, and the ramifications for not reporting concussions. 9:05:36 AM MR. DEAN reported that often an athlete would only exhibit visible concussion symptoms for a short period, and that coaches and staff needed to understand that the healing process was not immediate. 9:06:28 AM REPRESENTATIVE SEATON directed attention to page 2, lines 25-26, and asked who would determine that a student be immediately removed from the practice or game. MR. DEAN replied that the onus to remove the student from competition or practice would fall on any adults involved. 9:07:13 AM REPRESENTATIVE P. WILSON asked for a further explanation to the dangers from early participation after a concussion. 9:07:39 AM MR. DEAN explained that research indicated that "a second strike syndrome" occurred if the first concussion had not been fully healed. He stated that this created "an exponentially higher rate of injury," though the exact reasons were not yet understood. He declared the necessity for full recovery of a concussion before play was resumed. 9:08:37 AM MS. SHELDEN added that medical professionals can often recognize symptoms which are not readily discernible. 9:09:16 AM JILL HODGES, Executive Director, Alaska Brain Injury Network, testified in support of HB 15. She reported that the seriousness of concussion and brain injury had been a focus in the last few years and that new information was being brought forward regularly as research continued. She pointed to studies from the NFL and the Centers for Disease Control and Prevention (CDC) which were now available to the public. She pointed out that many state legislatures were also passing bills emphasizing brain health and reducing the risk of serious injuries. She noted that, in Alaska, there were 800 people hospitalized each year with severe brain injuries. She reported that, since 2003, brain injury rates from car accidents had been reduced by 40 percent, possibly due to the passage of the seat belt law. She declared HB 15 to be a prevention and educational tool, and, as there was not a fiscal note, it was a very cost-effective means. It would educate student athletes, coaches, athletic directors, parents, and teachers. She stated that physical and mental efforts could slow the recovery rate, as there were metabolic changes occurring in the brain during recovery. She shared that many states had passed similar legislation and that communities were voluntarily going above and beyond the requirements of the bill. She described baselining as an examination for each individual, so that should a concussion occur, there was specific personal data for comparison. She encouraged support for HB 15, so student athletes could maximize their potential. 9:14:39 AM GARY MATTHEWS, Executive Director, Alaska School Activities Association (ASAA), stated that ASAA, with membership of more than 200 high schools, supported HB 15. He said that ASAA had worked on this legislation and he assured the committee that the membership was prepared to implement the bill. He pointed out that ASAA had a sports medicine advisory committee which was ready to implement concussion management, training, and regulation. He agreed with the necessity for the bill to be workable in all parts of Alaska. He expressed the importance for return to play only to be permitted by an authorized individual. He explained that the rules for high school sports were generated on the national level by the National Federation of State High School Associations (NFHS) with the express purpose to protect students from injury and to maintain standards for the games. The football regulations required the officials to be aware of impaired play or suspected head injury. He spoke about a better national awareness for cognitive impairment. He expressed support for the proposed committee substitute, Version M. He reported that Impact, or baseline, testing had been offered experimentally with some athletes in Alaska, but that it was very costly and had limited availability for rural schools. He stated that the ASAA was ready to implement the bill. 9:20:57 AM REPRESENTATIVE SEATON, pointing to page 3, lines 21-22, and noting that this referred to post concussion, asked about prevention of concussions. He asked if there was adequate protocol for the use of protective gear. 9:22:08 AM MR. MATTHEWS said that protective gear was specified in the national rule books for every sport, except soccer. He discussed the difficulty of developing gear that would not alter the fundamental nature of a sport. He cited that many youth organizations also followed the national federation rules. He directed attention to page 2, lines 16-17, which stated "the nature and risks of concussions." He opined that the risks could be reduced. He referred to the aforementioned Heads Up program, which taught safer ways to compete, and would hopefully eliminate some of the concussions. 9:25:06 AM REPRESENTATIVE KAWASAKI asked if all schools currently had a qualified person present during competitions. 9:25:13 AM MR. MATTHEWS replied that although many areas did not have the personnel on site, they could be standing by. He opined that it was more likely for onsite personnel to be at the highest risk sports of football, hockey, and wrestling. He stated that anyone had the opportunity to recognize concussion, and a check list could be used to determine whether a player needed further evaluation. Currently, if an Alaskan student indicated for a concussion, they were not allowed to return to play until the following day. He said that it would be very difficult to have a licensed provider at every contest. 9:27:34 AM REPRESENTATIVE P. WILSON asked whether baselines could be set during the required pre-season physical examination. 9:28:42 AM MR. MATTHEWS replied that every student was required to have an annual sports physical exam prior to participation in sports. He noted that it was more difficult in rural areas, but it was the rule and it did occur. He opined that there were very few people in Alaska to administer or evaluate the impact tests. 9:30:27 AM JIM NYGAARD, Superintendent, Cordova School District, stated support for HB 15, paraphrasing from a prepared statement, which read [original punctuation provided]: Thank you for the opportunity to testify in support of HB 15. It's a great time of year in Alaska. After a long season of basketball games, the state playoffs are just around the corner. Sports, especially basketball, are the glue that helps keep many of our smaller communities together during the long winters. And what a celebration each weekend is, when we can gather with friends and neighbors to enjoy a friendly rivalry on the court. Truly a great time for the superintendent of schools, at that point I know where all my kids are. Can you imagine the pain felt among the crowd when our athletes struggled for the ball, and one is no longer capable to regain his composure and come to his feet. We've all seen this, and we've all gasped in disbelief and denial that it could happen on our court in front of all of us. Now, imagine the coach, the players, and the parents. The many things that race through our brains at the time when a student athlete is sprawled on the floor trying to recover from a collision, there will never be a time when we are all more vulnerable and in need of (indisc.) coach to ensure that that student athlete will successfully recover. From this point, the final score means nothing, as long as the student athlete is capable of recovering. We're not doctors, nor can we guarantee that a doctor will always be present. I appreciate the sponsor's efforts to see the necessary language in the amendments reflect a qualified person, as in many communities, a licensed physician is not always available. Getting this language clarified has been monumental for all the schools involved in these conversations. As with all human nature, education is key. Getting the information out to the public will benefit all parties. Necessary sign-offs of the nature of risk of concussions by parents and student athletes will complement the need for all parties to be better prepared to deal with potential concussions. Legislative influence will add consistency to the adherence of this bill, as well. At a time when information is readily available via internet, we have limited reasons not to be better informed, nor to be more pro-active, especially when it has to do with the wellbeing of our young populations. I support this bill as it moves forward, and appreciate the committee's time as you listen to similar testimony throughout the morning. CHAIR DICK stated that public testimony would remain open. [HB 15 was held over.]