Suspected Concussion in a Final With Eighteen Minutes Left
Final match of a regional under-19 girls' football tournament, 18 minutes left, score 1-1. A 17-year-old midfielder and an opponent clash heads going for the same ball. There is no loss of consciousness; she is on her feet within 10 seconds and says 'I'm fine, I'm fine'. On the sideline she reports a headache at 4/10, 'pressure in the head', answers 'what is the score?' correctly, but repeats the same question about the time three times in two minutes. Her coach says she passed 'the concussion check' because she knows where she is and can walk in a straight line. The only medical cover is a first-aider with basic training; her parents are in the stand. The referee will allow a substitution only if she stays off. The bench has one outfield player who has not played all season.
1. State the immediate decision and the reasoning behind it, list the signs that would require emergency transfer, and explain whether she could return if her symptoms clear in ten minutes.
Read the worked answer
Decision: permanent removal for the day. No second-half return.
The repeated question is the concerning finding, not a harmless quirk. Repeating the same question means she is not orientated to the present moment, even though she knows the score and can walk a line. 'Knows where she is' is not a validated clearance test; a same-day sideline assessment is a screening tool, not a diagnostic or clearance instrument, and it is not designed to be passed.
Emergency transfer (call an ambulance) if any of: worsening or severe headache, repeated vomiting, seizure, unequal or unreactive pupils, drowsiness or difficulty rousing, slurred speech, weakness or numbness, double vision, neck pain, increasing confusion or agitation, unusual behaviour.
Monitoring. An adult stays with her for 2-3 hours, checking every 15-30 minutes. She is not left alone, not sent home alone, does not drive, and does not drink alcohol.
Why not a ten-minute recovery? Signs resolving quickly does not restore the brain to baseline - the neurometabolic cascade is still running while the player looks normal. Same-day return after a suspected concussion is not permitted under current consensus, precisely because a second impact in that window carries a disproportionate risk. Her 'I'm fine' is a symptom of the injury, not consent to play.
2. Describe the return-to-learn and return-to-play pathway, with timeframes and the limits of a Level 1 leader's role.
Read the worked answer
Return to learn comes first. 24-48 hours of relative rest (not a dark room), then graded school attendance: partial days, reduced screen load, rest breaks, then full days. Full return to learning must precede graded exercise.
Then the graded exercise strategy, minimum 24 hours per stage, symptom-limited:
- Light aerobic activity, 20-30 minutes at low intensity.
- Moderate aerobic activity.
- Individual sport-specific drills, no contact.
- Non-contact training drills, resistance work.
- Full-contact practice, only after medical clearance.
- Return to match play.
Any recurrence of symptoms means dropping back one stage and waiting another 24 hours. The whole pathway is at least a week and usually longer.
What the Level 1 leader may do: recognise and remove, monitor, communicate with parents and coach, document, and implement the graded stages once a clinician has set them.
What the Level 1 leader may not do: diagnose concussion, clear a player, design the medical progression, or decide that a symptom-free player may skip stages. Clearance for full contact belongs to a physician. If the family declines medical review, record the advice given and the refusal - do not substitute reassurance for assessment.
3. The coach is arguing about the scoreline and the missing substitutes. How do you handle the conversation, the parents and the paperwork?
Read the worked answer
With the coach. One sentence, in private, then stop debating: 'She took a head impact and is showing signs - she is off for the day, that is not a decision we can trade against the score.' Offer the substitution so the team is not punished for the correct decision. Do not hold the discussion in front of the players; a public argument invites the player to re-enter the negotiation and undermines the next removal.
With the parents. Call them to the sideline, describe what was seen (head clash, headache, pressure, the repeated question), state that she has been removed and must not return today, and advise same-day medical review with a written advice sheet. Give them the red-flag list. If they decline review, record that.
Documentation. Time of impact, mechanism, observed signs, the exact question repeated, who assessed, who monitored and for how long, who was informed and when, the removal decision. Write facts, not opinions about fault.
The ethical point to hold. The score, the substitution shortage and the fact that the tournament is a final have no bearing on the risk of a second impact in the same match. The player's own insistence is not evidence of capacity to decide - in a suspected concussion, 'I'm fine' is part of the clinical picture.