She focused the camera. Click. It was a hard hit, but he was getting up. Click. She kneeled to get a better angle of the player who was down. Click. Out of the corner of her eye she saw players congregating just across the field from her. With her camera still at her eye, she turned to take photographs of them. Click. Another player was down. Click. She zoomed in to see who it was. Click. The player was lying on his back. Click. She zoomed in a bit more. Click. As she zoomed in closer, she saw the jersey number. She dropped the camera and ran onto the field. It was Tommy, her son, and he was not moving.

It was May 23, 2009, just two weeks before Tommy Mallon's graduation from Santa Fe Christian High School in Solano Beach, and he was ready for college with a scholarship to Chapman University. In a second, his whole life changed.

"I was clicking away, and I didn't know it was Tommy," said Tommy's mother, Beth Mallon.

Seventeen-year-old Tommy fractured his neck in the last 10 minutes of his last high school lacrosse game. It was a moment that his whole family said they have had to re-live over and over as doctors' visits and rehabilitation continue.

"He did make it to graduation in a wheel chair," Mallon said. "He was able to stand up and get his diploma."

Tommy was fortunate, and doctors and athletic trainers across the nation have recognized that his case was unique.

"There was an athletic trainer on-site and if there hadn't been, her son would have probably been dead right now," said Mike West, the president of the California Athletic Trainers' Association.

According to West, Tommy's life was saved by 26-year-old Riki Kirchof, the certified athletic trainer who was on the sidelines when Tommy went down.  

"I ran out onto the field and Tommy just said, 'I feel funny. I feel funny.' So I thought he just had a concussion," Kirchof recalled. "I started evaluating him for a concussion. He had already taken his helmet off. Then he said that he could not feel the back of his head."

Kirchof said a parent who was a doctor ran onto the field and suggested they move Tommy off the field and evaluate him in the athletic tent. But after doing the preliminary evaluation to see if Tommy had a concussion, Kirchof recommended not moving him and calling an ambulance. They found out later that moving Tommy could have threatened his life.

Tommy Mallon during his stay in the hospital. (Beth Mallon)

Tommy had a fracture of his C1 vertebrae, which is the vertebrae closest to the skull. According to Children's Hospital of Los Angeles' Pediatric Neurosurgery Division Head Mark Krieger, M.D., if there is a spinal chord injury at that level, instant death can occur.

"There is a possibility that, had he gotten up and turned his head the wrong way, he could have severed his spinal chord and dropped dead right on the spot," West said.

People standing on the sidelines and other players who were on the field said the severity of the situation was unexpected because Tommy's hit did not look any worse than a routine lacrosse hit before he went down.

According to Jeffery Mallon, Tommy's brother, who was also playing on the field when Tommy was injured, Tommy and a member of the opposing team were both running to get a ball that was just yards in front of them on the ground. Tommy saw that the other player was going to get there first, so he went in, shoulder first, in a legal lacrosse hit. He slightly lowered his head and, when he did this, the other player lifted his elbow to the side, into Tommy's head.  

"At first it didn't look bad. You could pick 20 more hits from the same game that looked just like that one, and everybody was fine," Jeffery said. "I saw it happen, and all the coaches were saying they were keeping him down just as a precaution, but that he was fine. Then later my dad says, 'Your brother broke his neck.'"

Kirchof said the hit did not look like it would have caused a lot of harm, and if she had not been trained on how to properly evaluate a player she probably would have moved him off the field to ask questions. However, when she saw signs of neurological or neck injury she immediately began an evaluation on the field.

"We are trained that right when you find out about any kind of neck pain, you immediately stabilize their head and neck because you never know," Kirchof said.

Kirchof said she had him stabilized until the paramedics came and put him on a spine board. He spent the next three days in the intensive care unit and the following two weeks in a hospital bed.

Tommy is one of an estimated 6 million high school students nationwide who participates in high school sports, and his injury is just one of more than 715,000 sports-related injuries that occurred within the last year. According to the 2009 American Journal of Sports Medicine, more than 125 students died as a result of an injury in the last two years. 18 of these deaths occurred in California.
 
Mallon and West said Tommy could have become a part of these statistics if the proper care had not been immediately administered. Tommy's mother said the question that still runs through her mind is what would have happened if the athletic trainer had not been there.

"Tommy was extremely lucky to have an athletic trainer on the field at the time of injury," Mallon said, "He wanted to get up, but the athletic trainer just said, 'No, you're not getting up.' I don't know what a coach would have decided."

According to the California Athletic Trainers' Association, there is not an existing law mandating certified athletic trainers to be at high school sporting events, and oftentimes it is left up to coaches to make informed decisions on how to handle injuries. According to Advocates for Injured Athletes, only 42 percent of high schools across the nation have athletic trainers available at high school games and most of them only attend football games.

There is a large gap between the knowledge and training of a certified athletic trainer and the knowledge and training of high school coaches, according to Roger Blake, the associate executive director and director of health and safety for the California Interscholastic Federation, the organization that helps regulate the rules and the responsibilities of California schools in regard to high school athletics.

"To compare the knowledge of a coach with an athletic trainer, that's night and day," Blake said. "They are not even close, but their roles in what they do are significantly different."

Tommy Mallon with his teammates before the injury. (Beth Mallon)

According to Blake, coaches of high school sports are trained as first responders and are only required to have First Aid and CPR certification. Certified athletic trainers have had extensive education in handling catastrophic injuries.

"A certified athletic trainer must go through four years of classes," Blake said. "Their knowledge and ability oftentimes exceed the knowledge of the emergency responders. The athletic trainers have the knowledge and ability on par with a nurse practitioner, and they sometimes have more expertise than a paramedic."

Leonard Hudson, the head coach of the football team at Garey High School in Pomona Unified School District, said he has been coaching football for 14 years and has seen about seven catastrophic head and neck injuries during his coaching career. He said if it were not for his college education in kinesiology and special athletic training courses he chose to take, he would not have been prepared to deal with the high risk situations that resulted from catastrophic neck and head injuries.

"The coaches classes that are offered and required do not train coaches to recognize those injuries that could be life threatening like spinal injuries or concussions," Hudson said. "It really ends up being left up to a coach's individual background."

On January 12, California Assemblywoman Mary Hayashi introduced Assembly Bill 1646, a bill that will "add training on concussions and other potentially catastrophic injuries, such as asthma attacks and heatstroke, to the CPR and first aid certification required of all California high school coaches," according to the California Democratic Caucus.

Courtney Watson, the athletic trainer for the Los Angeles Sparks, said the mandated additional training for coaches is necessary because many coaches do not take optional athletic training courses.

In April, Watson scheduled two athletic training clinics on two different days for high school coaches in Los Angeles Unified School District, and she had to cancel both of them because coaches did not sign up.

Blake said this additional training, in conjunction with the current First Aid and CPR classes, could help prevent students from returning to play too soon. In Tommy's case, the athletic trainer immediately recognized that he should be evaluated for a concussion and, according to Blake, this immediate response was key in identifying that there was a severe injury that required stabilization.

According to Hayashi, 41 percent of students who sustain concussions during play are allowed to start playing again prematurely because coaches are not trained on how to identify the signs and symptoms of concussions.

Krieger said he has seen two high school athletes die in the last year from sports-related injuries at Children's Hospital Los Angeles because they were not evaluated in a timely manner and were allowed to return to play after sustaining a concussion.

"It's the second hit that often causes the most damage," Krieger said. "In many cases, an athlete can sustain a concussion and on the second hit there could be rapid brain swelling, resulting in death."  

Ken Taylor, the sports medicine doctor and head team physician at University of California San Diego, said even with this added material in classes it could still be difficult for coaches to identify a concussion because they are still not trained medical professionals. He said the training they would receive would still be minimal compared to the years of education that certified athletic trainers and sports medicine doctors go through.

He also said that coaches often depend on students to tell them how they feel in order to evaluate injuries.

"It can become a problem because a lot of times athletes feel like that they have to be tough, and they won't admit to a headache," Taylor said. "It is about asking the right questions in the evaluation and once someone is around it more, it become easier to identify the injury."

Taylor said he was working at a high school football game six years ago, and he had arrived late. Before he arrived, one of the players had been hit, but the coaches did not recognize anything unusual about the hit. The player did not report anything. He just went to the sideline and sat on the bench. A little after Taylor arrived at the game, the player began to vomit and then passed out.

"He had swelling in his brain, a couple of surgeries and months in a rehab hospital," Taylor said. "He mostly recovered, but not completely. And I just think what if someone had reported something or said something sooner? Could that catastrophic injury have been prevented?"
       
The athletic trainer at Tommy's game, Kirchof, said injuries, especially concussions, can go unnoticed if there is no one at the game looking specifically for injuries.

"Coaches can get caught up in the play, and when an athlete does get injured there's always pressure from parents and players to get the injured player off the field quickly," Kirchof said. "And then there's always hesitation when deciding to keep an athlete from playing."

Blake said CIF hopes to pass a rule by August that will mandate that players who have the signs and symptoms of concussions be evaluated by a doctor before returning to play. Assembly Bill 1647, another bill introduced in January by Hayashi mandates that students suspected of a concussion be seen by a doctor before being cleared to play.

The bill also provides title protection for certified athletic trainers.

Tommy Mallon playing lacrosse before the injury. (Beth Mallon)

California is currently one of two states in the United States that does not have title protection for athletic trainers, which means that any individual can apply for a job at a school and say they are an athletic trainer because they are not required to show a license or certification, according to the California Athletic Trainers Association.    

According to Brian Roberts, the director of sports medicine at the Casa Colina Rehabilitation Center and member of the National Athletic Trainers Association, a similar bill was vetoed by Gov. Arnold Schwarzenegger twice because he thought it would add unnecessary bureaucracy. Roberts said the bill will ensure that schools hire trainers who can respond quickly to catastrophic injuries.

"Right now, someone can learn how to tape an ankle and then go and get hired as an athletic trainer," Roberts said.

According to the NATA, certified athletic trainers require about four years of training, and to become certified trainers must pass the NATA Board Exam.

"If you can qualify to take the test and you pass it, you know what you're doing," Roberts said.

According to CIF, the bills are currently in a suspension folder until an appropriations committee reviews them and the state budget is finalized in June.

Tommy and his mother have been to Sacramento on three separate occasions to lobby for the bill, saying they hope this is a move toward the state mandating school districts to have certified athletic trainers at every athletic event.

Blake said this may sound like a good idea on paper, but realistically most California school districts cannot afford to hire full-time athletic trainers.

"School districts are laying off so many people right now," Blake said. "75 percent of the athletic staff at a lot of California schools are being let go. It would be nearly impossible for any school districts to hire on completely new full-time positions."

According to Hudson, part-time certified athletic trainers in Pomona's school district have left to take jobs in districts that are hiring full-time certified athletic trainers. He said that not only is the district left with some trainers who are not certified, they also do not have any trainers available for practices.

"In practice we have repetition with hard hits happening over and over and this is when we really need the trainers," Hudson said.

Superintendent of Pomona Unified School District Richard Martinez said they have team doctors at every game and are currently working on a contract with Casa Colina Rehabilitation Center to have certified athletic trainers available every day for practices and games.

After Tommy's injury, his mother began Advocates for Injured Athletes, a foundation that not only supports the families of those injured in sports-related accidents, but also assists schools in funding certified athletic trainers.

Martinez said the contract he is working on to get athletic trainers for Pomona's schools would cost $12,000 per school. Mallon said her foundation will take private, public and corporate donations to help fund large expenses like this for schools that are financially stable but need extra help to obtain certified athletic trainers.

Even if it is not possible for the state to mandate that schools have certified athletic trainers at every athletic event, Mallon said she is happy that her efforts are raising public awareness.

"And I think that's what Tommy's story is doing, it's raising public awareness," Mallon said. "Fortunately we have a happy story. He's recovering now, so we have something that went really right."