Medical science was a lot less sophisticated in 1957, the year Bob Paroli first became a high school football coach. Back then, players didn't suffer concussions. They simply had their "bell rung."
Or as Paroli liked to refer to it, they got hit so hard that they started "counting their change."
It's a phrase the old coach coined late in his rookie season 50 years ago to describe a star halfback at Benson High School.
The player, whose name Paroli has long since forgotten, took such a severe blow to the head that he spent halftime walking around the locker room talking to himself.
And things only got worse as the night wore on.
"You could tell something was amiss," recalled Paroli, now the head coach at Seventy-First. "All the way home on the bus, he kept reaching into his pocket, pulling out whatever silver he had, counting it, putting it back in his pocket and doing it all over again. By the grace of God, he recovered from that."
Divine intervention is no longer the sole factor in the diagnosis and care of football-related head injuries.
Through years of research and scientific advancement, doctors, trainers and coaches are now able to detect concussions almost as soon as they happen. More importantly, they have a much better idea of how to determine when it is safe for players to return to action.
Because today's athletes are bigger, stronger and faster than those in the past, their collisions have become progressively more violent. As a result, they're suffering more concussions than ever.
A study by Massachusetts doctor Robert Cantu shows that as many as 250,000 high school football players suffer concussions each year. That's nearly 20 percent of all players nationwide.
The problem is just as widespread among the college and professional ranks.
Although there are no hard statistics available to determine the exact number of head injuries that occur -- in part, because many are never reported -- the National Football League thought it was enough of a concern to hold a summit on the subject in Chicago this summer.
"We've described it as sort of a hidden epidemic," said Dr. Kevin Guskiewicz, chairman of the University of North Carolina's department of exercise and sports science and a participant in the NFL's recent conference.
Of particular concern is a clinical study of more than 2,500 retired NFL players, which concluded that those who sustained three or more concussions were more likely to have memory problems, chronic depression or Alzheimer's disease later in life.
There is also growing speculation that brain damage may have been a factor in the deaths of former Philadelphia Eagles safety Andre Waters, Pittsburgh Steelers lineman Mike Webster and others.
"If these things are misdiagnosed or go undiagnosed, they could end up with a catastrophic outcome," Guskiewicz said. "The way the brain moves inside the cranial cavity and responds to acceleration and deceleration types of forces, there's no way to prevent concussions. But I certainly think we can, following some guidelines, do our best to try to minimize them, reduce the severity of them and help the recovery process."
The first and most important step in the process is determining exactly what a concussion is.
Most certified trainers agree that it is a type of injury, caused by a blow to the head, that results in a change in mental status. Among the most common symptoms are dizziness, headaches, blurred vision and in the most extreme cases, loss of consciousness.
But even that definition can be subjective.
Before retiring a week into training camp in early August, Carolina Panthers safety Mike Minter admitted that he sometimes felt "woozy," or even "saw stars" upon making a big hit. But despite being "unbalanced for a little bit," he resisted reporting his condition, because eventually "you're good and ready to go in again."
No one will ever know if those "dings," as they're sometimes referred, were actually slight concussions.
If they were, Minter could have put himself at greater risk for further injury.
"They've done a lot of studies on something called 'second-impact syndrome,' which is basically coming back too soon from a first concussion," said John Townsend, Fayetteville State's head athletic trainer. "The damage gets worse and worse with each and every concussion after that.
"You are more likely to get concussed and when you are, it's likely to be worse than the first one."
Minter's teammate, Dan Morgan, knows a little something about that.
He's suffered at least five of them in his six-year career with the Panthers.
The most recent, which happened in last year's season-opener against Atlanta, caused him to miss the final 15 games of the regular season.
But it may have been prevented had a similar blow in an exhibition game against Jacksonville been treated as a concussion.
"I got dinged up in the Jacksonville game, took the next week off, then came back against Atlanta and basically hit my head in the same place," Morgan said. "It happens."
It won't happen as much in the future if NFL commissioner Roger Goodell is as serious about concussions as he seems.
"You know our athletes are great competitors," Goodell said in a press conference following the league's concussion summit. "They want to play and they want to compete, but they also need to be protected from themselves sometimes."
Or as Merril Hoge, an ESPN analyst whose career as a fullback with the Pittsburgh Steelers and Chicago Bears was cut short by multiple concussions said, "It can't be a macho thing anymore."
The NFL can ensure that by having team doctors, as well as a full training staff, on the sidelines for each game. So can big Division I-A colleges, including North Carolina, N.C. State and East Carolina.
Most smaller colleges and high schools, however, can't afford such a luxury.
Fayetteville State, for example, employs just two full-time trainers for its entire athletic program.
And of the 10 high schools in Cumberland County, only three -- Douglas Byrd, Jack Britt and Pine Forest -- have a certified athletic trainer on staff. That's slightly less than the national average of about 40 percent.
"That's just terrible," Guskiewicz said. "We need to do something about it, because in my opinion, the first step in trying to tackle this problem is catching these injuries on the front line."
Fred McDaniel, the director of student activities for Cumberland County Schools, said that everything possible is being done to ensure the safety of local players.
It's just not easy finding enough certified trainers to go around, he said, since only a few are also certified as teachers.
Those schools that don't have trainers on staff use other qualified first-responders, such as EMS personnel, to treat on-the-field injuries.
Regardless of their credentials, they're all taught the same thing. When it comes to head injuries, err on the side of caution.
That's how Townsend handled quarterback Brian Hardy after he got kicked in the head as he dove for a fumble in the Broncos' season-opening game against Wingate.
The process started with a quick assessment of Hardy's cranial nerves the moment he got back to the bench.
Once Townsend finished checking the player's eye movement, sense of smell and other motor functions, he began asking a few basic questions to test Hardy's short- and long-term memory.
"What's your name?"
"What day is it?"
"What did you have for breakfast?"
"Who was the first person who talked to you out on the field?"
"Do you hear any ringing in your ears?"
"Can you count to 10 backwards?"
Because of the responses and the dazed look in Hardy's eyes, Townsend recommended that the youngster be taken to the hospital as a precaution.
It's a good thing he did, because until watching the play on film two days later, Hardy had no memory of what had happened to him.
"The only thing I remember was lying in the hospital bed," said the quarterback, who returned to action after being sidelined for two weeks. "I was really out of it. I kept wanting to doze off, but they wouldn't let me."
The reason concussion patients are discouraged from sleeping, Townsend said, is so that doctors can continue to monitor their symptoms.
Among the most serious complications is a condition known as a subdural hematoma, or a slow bleed inside the brain.
Though rare, it can be fatal if not detected and treated.
Hoge has first-hand knowledge of how dangerous concussions can be.
In 1994, after suffering his second concussion in three weeks during a nationally televised Monday Night game against the Buffalo Bills, he stopped breathing while in the locker room at Chicago's Soldier Field.
"The message should be clear. If there is head trauma, get that player to the proper people who are experts in that field," Hoge said. "Be aware of the symptoms -- coaches, parents -- and get your child properly evaluated. Then do not let them return to play until they're cleared."
Though each case should be evaluated individually, FSU trainer Townsend said that the general rule is to hold a player out of action until he has gone a full week without any symptoms.
McDaniel said that according to Cumberland County school policy, anyone suffering a concussion must be first cleared by a doctor before even returning to practice.
To aid the diagnosis, many neuropsychologists are turning to computer programs to determine how players are recovering from head injuries.
The most widely used is the IMPACT System, developed by Dr. Mark Lovell of the University of Pittsburgh Center for Sports Medicine.
"The system, which is overseen by doctors and athletic trainers, basically monitors reaction time and thinking speed, as well as basic aspects of memory," said Lovell, whose program is used by all 32 NFL teams. "It has a lot of advantages, because it can measure reaction time much more accurately than with a stop watch and it made these tests to schools out there where it's really needed."
In addition to providing post-concussion data, the IMPACT System also allows teams and schools to have baseline readings on file against which to compare them.
But as helpful as the computer program is, Guskiewicz warns that it's still not a substitute for daily interaction between medical professionals and their patients.
"There are certain things you can't tell with a computer," the UNC professor said. "I'm a big proponent of balance testing.
"These athletes are very agile people. If their balance is off, what good is sending them back onto the field?"
None, said N.C. State center Luke Lathan, who thought he was ready to return from a concussion suffered last season after about two weeks until a trainer asked him to stand on one foot.
He couldn't do it.
"My wife said that was the most horrible time for her," Lathan said, "because she couldn't stand to see me fall over all the time."
It eventually took Lathan another two weeks before playing in a game.
And the precautions didn't stop even after he took that first hit and realized he was all right.
At his preseason physical this fall, nearly a year after his injury, the Wolfpack's team doctors made it a point to ask him if his helmet checked out, if his balance is OK and if he's had any trouble with his vision?
Those are questions Seventy-First's Paroli probably never would have thought to ask when he first got into coaching.
But if he's learned anything over these past 50 years, it's that it pays to be cautious anytime a player starts counting his change.
"Of all the injuries kids are subject to having, that's the one you don't want to play around with," he said. "You can rehabilitate a sprained ankle and repair a torn up knee. You can even replace a hip. But you can't replace a brain. Once that's gone, you can never get it back."Staff writer Brett Friedlander can be reached at firstname.lastname@example.org or 486-3513.