PART 1: Remembering Rowan Stringer, whose cautionary tale should enact new concussion protocol in Canada
CALGARY — Rowan Stringer was born with the heart of a caregiver.
For every trip to the grocery store, every trip out of the house, Rowan dutifully clothed her doll, Mikaela, in real diapers, sleepers and knit caps.
She pushed Mikaela in the baby swing, put her down for naps in the playpen, and pretended to spoon-feed her in the high chair.
“Rowan had the most nurturing personality,” says her mother Kathleen. “She took care of Mikaela from the day she got her until she was quite old. I remember telling her, ‘Maybe you shouldn’t take her to school,’ because I was afraid she would get bullied.”
That nurturing quality grew with her. By Grade 11, Rowan was working as a co-op student in the playroom at the Children’s Hospital of Eastern Ontario. In Grade 12, she enrolled in the University of Ottawa’s nursing program for the fall 2013 semester with an eye to becoming a paediatric nurse.
She never made it to the first day of class. Rowan, a talented rugby player, died at that very same hospital on May 12, 2013 — Mother’s Day — after suffering two concussions within a week while playing the game she loved. She was 17.
“Nothing can stop me!” Rowan wrote in a text message to her best friend the night before the game that would end her life. “Unless, I’m dead.”
Her death triggered a coroner’s inquest that cast a harsh light on youth sport concussion protocols in Canada, which fall far short of those implemented south of the border. The first of the jury’s 49 recommendations, released in June, called for Ontario to adopt “Rowan’s Law,” an act governing the management of youth concussions in all sports. Nepean-Carleton MPP Lisa MacLeod, who represents Rowan’s riding, is scheduled to introduce a private member’s bill Wednesday that would establish a committee to determine how best to act on those recommendations.
All 50 U.S. states have laws dictating the management of youth concussions. In Canada, Ontario would be the first. The Liberals tried to pass a bill in 2012, but it didn’t survive the suspension of the legislature by then-premier Dalton McGuinty.
Seven months later, Rowan Stringer suited up for her final game.
“Would knowledge of concussions have prevented her death? I think there’s a good chance it would have, if she had been more clued-in,” says Dr. Charles Tator, a neurosurgeon at the Krembil Neuroscience Centre of Toronto Western Hospital.
“In fact, she did try to clue herself in. One of her texts indicated she had Googled ‘concussion’. But she didn’t read enough, or it didn’t sink in enough, to prevent her from playing in that final game that took her life.”
Rugby Canada's staff and players would like to extend our deepest sympathies and condolences to the family and friends of Rowan Stringer.— RugbyCanada (@RugbyCanada) May 13, 2013
Concussions among professional athletes have dominated sports headlines in recent years. NHL star Sidney Crosby sat out for months. Enforcer Derek Boogaard, who died of a drug overdose, had three documented concussions — and perhaps many more that went unreported — during his career. Rick Rypien, another hockey pugilist, committed suicide.
The National Football League, accused of hiding the risks of repeated head injuries for years, is facing a $1-billion concussion settlement with thousands of former players. The settlement is currently under appeal.
Both leagues have adopted new concussion protocols over the past few years. The NHL introduced new rules in 2011 that require players to leave the bench and report to a quiet room for assessment by a doctor after taking a hit to the head. The NFL went a step further in 2013, requiring a player with a suspected concussion to receive clearance from the team doctor and an independent neurologist before returning to play.
Yet there are few such rules governing youth sports in this country. That’s despite the fact that in 2012, the Canadian Paediatric Society called for a statute requiring all regional sporting associations and school boards to develop a written policy on concussion recognition and management. Concussions, the society said, account for nine to 12 per cent of all high-school sports injuries.
In 2009, Washington became the first state to enact a concussion law. It’s named after Zackery Lystedt, a 13-year-old football player who suffered a life-threatening brain injury after he returned to action following a hard hit earlier in the game.
“I’m totally shocked, because typically in Canada we’re more progressive as far as health care goes and safety,” Kathleen Stringer says. “In the States, they realized this is serious, this is dangerous, and this is worth having legislation.”
In the absence of American-style legislation, the current Canadian system is a patchwork of policies and rules adopted by national, provincial and local sporting bodies.
“We found out in the Rowan Stringer inquest that some leagues had done nothing about concussions — zero,” Tator says.
That’s frightening, he says, given science suggests young brains are particularly vulnerable to injury.
“We do think the adolescent brain is the most sensitive brain to the effects of concussion,” says Tator. “We used to think the infant brain was the most sensitive to trauma, but it appears now, because of the huge number of connections that are being made during adolescence, there’s a reason to worry more about adolescents getting concussed. They certainly take longer than adults to recover.”
Dr. Karen Barlow, a paediatric neurologist specializing in traumatic brain injury and concussion at the Alberta Children’s Hospital, sees first-hand the impact of concussions.
“When I see the kids, they’re often pretty down,” she says. “They’re pretty fed up. They’ve had persistent headaches, often for months. They find it more difficult to do their schoolwork, because they find it difficult to concentrate and attend. They haven’t been allowed to go back to play sports, so they’re feeling socially isolated from their friends. When we see these kids, it’s often quite sad.”
The number of youth they’re seeing is on the rise.
Doctors used to treat 100 to 150 children a year with persistent concussion symptoms in the Alberta Children’s Hospital traumatic brain injury program. That number is expected to hit 400 this year — three to four times what it was three years ago.
An Ontario study published in 2014 found the total number of visits for paediatric concussions to emergency departments and physician offices jumped to 14,886 in 2010 from 8,736 in 2003. During that period, the rate per 100,000 population increased to 754 from 467 for boys and to 441 from 209 for girls.
It’s unclear whether youth are getting concussed more frequently, or whether — as doctors suspect — more concussions are being reported, particularly given media coverage of concussions in pro sports.
Despite the huge jump in numbers, many concussions go unreported.
A 2013 study — conducted jointly by the University of North Carolina at Chapel Hill, A.T. Still University in Mesa, Ariz., and WakeMed Health and Hospitals in Raleigh, N.C. — found that up to 40 per cent of concussions suffered by U.S. high-school athletes were never reported to coaches or medical officials. There is no reason to believe those numbers would be much different in Canada.
Too often, young athletes are afraid to let down their teammates, their coaches, their parents. They don’t want to miss the big game, to jeopardize a scholarship, to look weak.
As Molly Tissenbaum, a hockey goalie at Harvard University, can attest, kids sometimes need to be protected from themselves.
“If I had a dollar for every time I heard, ‘Suck it up and play through it’ during my career, I wouldn’t be on a student budget,” she says. “All of us seem to feel the team can’t win without us, and that’s a great feeling to have, because you feel like you’re important and contributing. But there’s no win that will ever be more important than your ability to function.”
In Grade 9, Tissenbaum played through a concussion with a berth to the provincial championships on the line.
“I knew I was doing the wrong thing, but it didn’t matter at that point,” says Tissenbaum, now 21. “I was still too young to realize that your brain isn’t something you can put in a cast and hope it will get better.”
Diagnosed after the fact with post-concussion syndrome, Tissenbaum endured what she calls six months of torture. She struggled to complete simple math assignments, alienated her friends and generally lived in an incoherent blur.
Her mother, Lisa, remembers it like this: “She was Jekyll and Hyde. As brilliant as she had been, she couldn’t come up with any answers at school. She was so frustrated by it. She was like the Tasmanian Devil. Not the real one, the one we all know from the Warner Bros. cartoon. Things were all over the house. She couldn’t remember where anything had been put, so she would just whirl around looking for what it was that she thought she put down, and it was always right beside her. She was not on her game at all.”
Molly says “Rowan’s Law” could help change the way kids feel about taking an injury break. As detailed in the Stringer inquest report, it calls for:
- Medical clearance of all concussed athletes before they return to play.
- Mandatory concussion education for all young athletes, parents and coaches.
- The immediate removal of a young athlete from play if a concussion is suspected.
- Strict adherence to return-to-learn and return-to-play protocols for youth athletes with concussions.
Ontario is ahead of the other provinces with concussion protocols. In January, following Rowan’s death, it became the only province to institute a policy that specifically deals with concussions that happen at schools. The policy requires all school boards to have concussion education programs in place and rules to manage students who suffer one. But the policy does not cover concussions suffered in community-based sports leagues.
If Ontario adopts the inquest recommendation, it would bring the province in line with the U.S., governing concussions suffered by youth in any arena or field of play.
Exactly why the U.S. is so far ahead of Canada when it comes to concussion laws is unclear. Layth Gafoor, managing partner of Lucentem Sports & Entertainment Law in Toronto, says it could be because the U.S. is far more litigious.
“People get sued for large amounts of money, far more than they would in Canada, and so, for them, at the federal and state level, it becomes a matter of exposure,” he says. “I don’t think anyone is taking the issue of concussions as a sitting-down matter. It’s a priority for any state or provincial government.”
Tissenbaum says mandatory concussion protocols would protect those who might not be able or willing to protect themselves.
“I think this law is going to be a very important first step in recognizing that saying, ‘I’m injured, I cannot play,’ is not a sign of weakness,” she says. “It’s mind-blowing the number of kids who are in organized sports, and they’re vulnerable to these things, because there’s nothing protecting them except their own ability to say ‘I’m hurt’ or ‘I’m not.’ Having been an athlete, I know that might be the single most difficult thing to say.”
The recommendations from the coroner’s inquest have no weight outside of Ontario.
But the Stringers hold out hope that their daughter’s death will serve as a wake-up call for Canada. They don’t want one more child to die, or another family to go through the agony they went through when doctors told them there was no hope and their daughter was taken off life support.
“Perhaps if Ontario gets its act together on this, then maybe it can be used as a template for other jurisdictions to follow suit,” says Rowan’s father, Gordon.
“For us, it would be so devastating and upsetting if another child in Canada were to die the same way,” Kathleen says. “We know that it’s preventable.”
They can’t help but wonder what the future might have held for their nurturing girl, whose goal in life was to care for children.
“Here’s a young girl who had a lot of things going for her, big plans for her life, and her plan was to help people,” Gordon says. “She was going to go into nursing. She volunteered at the children’s hospital here. And she wanted to be a nurse at that hospital. This was her plan for the future. So we thought, in an indirect way, if we do something like this and raise awareness and hopefully help another family to not go through what we’ve gone through, then in an indirect way she’s succeeding in what her dreams were.”
HER FINAL DAYS
Friday, May 3, 2013: Rowan Stringer, captain of Ottawa’s John McCrae High School team, plays three games in an all-day rugby tournament. Her mom steps out briefly after the second game for a Tim Hortons run and returns partway through the third game. While she is gone, Rowan is hit in the head. She goes to the bench, shakes it off, then returns to the field. In the evening, she complains to her mom of a headache and asks for a painkiller, but does not mention the incident in the game.
Monday, May 6, 2013: Kathleen Stringer travels to Brandon, Man., for work. Rowan plays another game in which she is dragged to the ground and kicked in the head. The headache returns.
Tuesday, May 7, 2013: Rowan is not feeling right, as evidenced by her exchange of texts with friend Michelle Hebert.
“I might have gotten a concussion ... have a headache again,” she writes.
“How was your game?” Hebert asks.
“Well I smashed it on the ground and then got kicked in the head.”
“Doesn’t that happen every time?”
“Which is why I probably have a concussion.”
“Ya well,” Hebert replies. “You need to stop dying ... Are you still going to play on Wednesday?”
“Yeah. Nothing can stop meeee! Unless I’m dead.”
“I’m sure you’ll be fine by then.”
“Are you going to get it checked?”
“Nope. Just see if it gets worse.”
Hebert suggests Rowan go see a doctor.
“Meh, what’s some brain damage gonna hurt?”
Wednesday, May 8, 2013: Rowan suits up for another rugby match. In the second half, she is grabbed by the shirt and thrown to the ground with an illegal swing tackle. Rowan lands on her head. She sits up momentarily, then falls back to the ground, losing consciousness. She is rushed by ambulance to the Children’s Hospital of Eastern Ontario.
Saturday, May 11, 2013: Kathleen Stringer climbs into her daughter’s hospital bed, rests her head on her daughter’s right shoulder and wraps her arm around her body. She sings the same lullabies she used to sing when Rowan was a baby. That night, Rowan is wheeled into the operating room where — in a final act of kindness, according to her previously stated wishes — surgeons remove her heart, lungs, liver, pancreas, kidneys and corneas for organ donation.
Sunday, May 12, 2013 (Mother’s Day): Doctors complete surgery on Rowan Stringer. Her official cause of death is second-impact syndrome, a rare condition when a second concussion occurs before a previous one has time to heal, causing severe swelling of the brain.
— Vicki Hall
Have you ever suffered a concussion?