The Robert Back Case
"There were multiple points of failure through this whole case, but there were so many opportunities to do this right."
Mickey Collins, PhD
The following story is a horrible tragedy and the result of poor communication. Below is a brief chronology of events based on several articles in the news. (1, 2, 3)
Sept 5, 2014 (Friday): Robert Back played in a high school football game and sustained a possible concussion.
Sept 6, 2014 (Saturday): Robert experienced nausea and headaches and was brought by step-mother to an Benefis Emergency Room - Dr. Nicholas Burham. He was diagnosed with a 'minor closed head injury.'
"Buck [father] didn't go with Back and his wife Shannon to the Benefis emergency room on Saturday, Sept. 6, 2014, the day after Back sustained an initial concussion in a football game, he said. The next day, he didn't read the discharge paperwork issued by a Benefis doctor stating Back had likely suffered a concussion, and should refrain from playing football until cleared by a physician, he said." (9)
"She said Thursday that Dr. Nicholas Burnham offered to complete a CT scan, but didn't push the idea, so she didn't think it was fully necessary.
"It's such a big test, why would you just offer it?" she said. "I was just confused by the stress of what to do." (10)
Sept 8, 2014 (Monday): Robert called his father to tell him he did not feel well.
"He knew his son wasn't feeling well, after complaining over the weekend of headaches and especially on Monday morning when he called to tell Buck he had thrown up in the shower, he said. But he suspected dehydration was the source of the sickness, he said, after watching the football game the previous Friday and thinking the players weren't drinking enough water."
Sept 7 – 9, 2014(?): Robert stayed home from school.
Sept 10, 2014: Robert saw a Great Falls clinic doctor, Thomas Triehy, MD, who "who told him not to play football until Sept. 15 and gave him a note to be given to his coaches." (8)
Brenda Loser, a Great Falls Clinic nurse who took the call from the Backs to set up an appointment, also said Tuesday the family was requesting clearance for Back to return to football play on Sept. 10, 2014.
"They were wanting to get a release to play football. They asked 'Do you do that?' I told them, 'No we did not,'" Loser said.
Triehy was taking same-day appointments, however, and the family took an appointment that afternoon.
Buck and Shannon both testified last week that they sought to find Back a new primary care physician that week, after a Benefis doctor who initially diagnosed a concussion told them he should see his primary care doctor.
During the appointment, which Triehy said did not make Back his established patient, Buck was "adamant" his son did not suffer a concussion, Triehy said. He instead argued with Triehy that he saw players not drinking enough water during the football game the previous Friday, Triehy said.
Buck told Triehy he had even watched film from the game and never saw a head-to-head hit that could have produced a concussion, Triehy said.
"He was very animated that they watched the film, there was no hit... it couldn't be a concussion because he was never hit," Triehy recalled Buck saying.
The doctor said the parents made him aware of certain symptoms, such as nausea and vomiting, but the doctor only found out Robert Back was having headaches by asking the 16-year-old directly. He said there "isn't a specific test for a concussion," but he had a high suspicion of one considering one other doctor had diagnosed one and the fact that Back had a headache.
"Especially given after three days after rest and hydration, he still had a headache," Triehy said.
Triehy said Buck still disputed his determination.
"The father wasn't happy," he said. "He eventually left the room before anybody else did. He was upset... He wanted a note so Robert could play Friday."
Buck also admitted to the verbal dispute in Triehy's office, saying "he had his feelings hurt, but he explained it to me.""I just wanted what's best for the patient, so I was irritated that my message wasn't being communicated," Triehy said Tuesday.
By all accounts, Triehy gave the Backs some concussion-related documents at the appointment and said Back should stay out of football until the following Monday. Whether Triehy got his next point across or not, is not fully known.
Triehy said he told the family that Back should follow up with another doctor before he played because he still was not free of concussion symptoms. He said he mentioned the school's "return to play" policy but said the family shouldn't engage in that process until Back was symptom-free.
"Do you believe you made it clear to everyone that Robert was not to play football until he was symptom-free?" asked Benefis attorney Julie Lichte. "I would have to hedge on whether the father knew because he didn't stay for the whole visit," Triehy answered. He said the family asked for a note to give to Back's football coaches, and he obliged with a handwritten note on his prescription pad. The family has testified they trusted Back to give the note to head football coach Jeff Graham, and today believe he did provide Graham with the note.
All football coaches who testified during trial said they never received the note. Back family attorney Steve Shapiro pointed to Triehy's own notes on the appointment, which didn't definitively claim Back had suffered a concussion.
Triehy said the symptoms, including a headache, didn't absolutely amount to a concussion but said there was enough evidence to suspect one. The discharge plan from Triehy also didn't mention anything about seeing a doctor before Back was cleared to play football again. It also doesn't mention anything about being "symptom-free" before he began the return to play process.
Triehy's note reads: "My recommendation was that he refrain from any further contact and begin 5-step return to play program as outline in the handout. If Monday he had no headache, he could return to full-contact practice and play next weekend. Parents are understanding of this, and they will let us know if he has ongoing problems or any questions.
The Backs understood when they left that Triehy believed their son had suffered a concussion but ultimately they believed Benefis athletic trainer Jessica Hansen and Graham when they later cleared Back for football.After meeting with Triehy, Graham administered an imPACT test for Back.
The next day, Sept. 11, Hansen reviewed the test results and told Graham that Back looked "OK concussion wise," which led Graham to believe Back could return to play.
(03/20/18)
ImPACT test administered by Coach Grant administered. He administered a baseline test, not a post test. (8)
Coach denied receiving doctor's note from Back.
"Later that night, Graham administered an imPACT test to "rule out" a concussion, he testified last week. He also said Back never gave him the note from the clinician and never knew any doctor had diagnosed a concussion."
"[Head Football coach] Graham had reached out to her on Sept. 10 to ask about doing an imPACT test. She said it was possible he could have the flu, since a few others on the football team did, but added "u can if u want," regarding the testing. Hansen said that exchange happened after Graham already had administered the test, disputing Graham's testimony.
Still, Back family attorney Steve Shapiro said, Hansen also wrote in her email to Graham that he should administer the "post-injury" test rather than the "baseline" test, which was given to Back on Sept. 10. Allowing coaches to test athletes on their discretion, rather than a physician's discretion was against Benefis protocol and procedures, according to the documents shown at trial Monday."(7)
Sept 10, 2014: Robert came to football practice. (03/08/18)
The following Wednesday, when he came to practice, Back wasn't very forthcoming with the information surrounding his doctors visits, Lake [assistant football coach] said.
After a year, Robert Back continues to rehab.
"I might have a concussion," Back told Lake, as Lake recalled from the witness stand Thursday.
Lake asked him once or twice if he had a note from a doctor, but Back just pointed to his pocket and made some gestures like it wasn't a big deal.
"That was the first time a child has never shown me a note," Lake said.
The note was important because earlier that day Dr. Thomas Triehy of Great Falls Clinic had written on the note not to return to football until cleared by a doctor. Attorneys agree that was the last time anyone saw or heard of that note.
Robert handed the doctor’s note to his football coach. The athletic trainer instructed the coach to give Robert the IMPACT Test. Robert took the test (the IMPACT test is supposed to be performed as a PRE-INJURY test to be used as a baseline in case of a future concussion).
Sept 11, 2014: the trainer reviews the test and states that Robert passed the test (No one passes this test. Again, it is a baseline indicator which is compared against future testing to determine if there is still a problem).
"After she reviewed the test results on Sept. 11, Hansen emailed Graham to say he looked "OK concussion wise," which led Graham to believe Back was OK to play that Friday, he said. Hansen said Monday that language was not meant to clear Back for play, but that she never knew he was out with a concussion." (7)
Sept 12, 2014: Robert is cleared by the coach/trainer to play in that night’s game. He plays in the game. The father is in attendance! Robert “did not sustain any big hits,” yet he collapsed on the sidelines after halftime. He was taken to the hospital and had an emergency craniotomy.
On Sept. 12, 2014 Back did play when he wasn't supposed to. As Lake tells it, Belt was beating Chester-Joplin-Inverness so badly that Graham had told him to get the younger kids ready to take the field.
"I was working with the younger kids when one of the kids said 'Coach, Robert just fell down,'" Lake said, fighting back the tremble rising in his voice. "It was very apparent Rob was hurt."
Lake said Hansen had already begun working on Back when he got to the spot where he collapsed. Back reportedly opened his eyes briefly before slipping into unconsciousness. Then he opened his eyes once more and coaches asked him, "Are you with us?"
"As best as I can remember," Lake said. "He said, 'Yes, I'm good,' and then he lapsed off and they couldn't get him to respond after that."
As Lake stood on the sideline, he said he remembers Shannon Back, Robert's stepmother and third-party defendant in the case, turn to Buck, Robert's father, and loudly yell, "I told you not to let him (expletive) play." (03/08/18)
The "lawsuit says Graham [football coach] or a trainer verbally "cleared" Back to play in the next game. He collapsed on the sideline." "The response says Graham did not receive a medical note or any information from the boy's doctor and did not clear Back to play the night he collapsed." (4)
The chronology of events points to one thing - a lack of communication and proper documentation.
All stakeholders - parents, coaches, trainers, school principal, school athletic director - must be informed of the Remove From Play and Return To Play decisions immediately.
All stakeholders must use the same method of communication. Phone calls, text messages, Facebook messages, emails, written and verbal communication can easily be misplaced, confused, and have little likelihood of being organized and recorded.
Documentation of Remove From Play and Return To Play is necessary for both health and legal reasons.
Stakeholder acknowledgement of each decision must be documented.
Update (5): "Attorneys for Robert Back, the high school football player who received substantial, permanent brain injuries while playing in a Belt High School football game in 2014, are now working to prove an athletic trainer employed through Benefis Health System should be held accountable for Back’s injuries."
Update (6): "Robert Back had been told by two doctors not to play football until cleared by a doctor, and one had given Back a note saying he should not play. "We never had a doctor's note that he was out," Graham said. "(Coach Alan) Lake never saw a note. I never saw a note. We never received it."
