Nottingham High School head football coach Jon Adams does not condone cut blocks. The play—in which a lineman hits his opponent below the knees, sometimes with his helmet—leaves the blocker prone to neck injury, due to the compromising position of the play.

And when Northstar guard Elias Hreiz performed one in the team’s game at Rancocas Valley on Oct. 9, that’s exactly what happened. His head collided with his opponent’s leg, and Hreiz immediately went down with pain and numbness in his neck. Because those symptoms can be indicative of a severe spinal or neck injury, a former RV athletic director trained in crisis situations rushed onto the field, stabilizing Hreiz’s head and neck to minimize movement—and the possible risk of further injury. Hreiz was strapped to a spine board and transported to Virtua Memorial Hospital.

His eventual diagnosis was a pinched nerve, and Hreiz was cleared to rejoin his team after a couple of weeks.

Others, though, are not so lucky.

This season, five football players from high schools across the country—including Evan Murray, the quarterback at Warren Hills High School in Washington, Warren County—died after on-field injuries. They range from a lacerated spleen (Murray) to blunt-force trauma to the head (Kenney Bui of Evergreen High School in Burien, Washington).

According to studies conducted by the National Center for Catastrophic Sport Injury Research, there have been a total of 31 fatalities over the last seven years. There have only been two years, the same study revealed, in which no deaths directly caused by high school football occurred: 1990 and 2012. In 1968, the NCCSIR reported 26 high school football-related deaths, the highest the number has ever been. The rate has stayed the same or decreased, for the most part, since then, due to elements like rule changes and more modern, effective equipment.

Additionally, in the same time period, nearly 100 high schoolers have died indirectly due to football, defined by the NCCSIR as the “result of exertion while participating in an acitivity or by a complication which was secondary to a non-fatal injury.”

Between 2008 and 2012, the NCCSIR reported more than 100 high school football-related catastrophic injuries, defined by the center as “fatalities, permanent disability injuries, serious injuries (fractured neck or serious head injury) even though the athlete has a full recovery, temporary or transient paralysis (athlete has no movement for a short time, but has a complete recovery), heat stroke due to exercise, or sudden cardiac arrest or sudden cardiac or severe cardiac disruption.”

The numbers are high, but the likelihood of death or catastrophic neck, spine or head injury is small—the most up-to-date rate of cervical cord and neurological injuries with incomplete recovery, and deaths directly related to high school football, is a fraction of one percent per 100,000 players.

Adams recalled playing through concussions in his playing days, just because the education wasn’t out there. He remembered after one particular hit, standing on the other team’s sideline and not realizing he was in the wrong place because he was so dazed.

“And I played the next weekend,” he said. “A kid has a concussion like that, they’re probably out a good month before we see them again, even to do their protocol.”

Still, the fact remains that football is an inherently dangerous sport. So in an emergency situation, how do local schools react? What is the best way to prevent catastrophic injuries, or worse?

Precautionary measures, some coaches agreed, are the key to keeping kids safe. Nottingham athletic trainer Samantha Quinnette said that while medical staff was near certain that Hreiz’s injury was not serious, he was taken to the hospital anyway just to be sure. In fact, Adams said he hadn’t even gotten to Hreiz before the decision was made—Quinnette and the RV athletic trainer made the call.

“As soon as they hear those words, ‘I have some pain in my neck, numbness in my neck,’ they’re going to spineboard you,” Adams said. “Any time they suspect those kinds of injuries, it’s immediate.”

Had it happened at Nottingham, Steinert, or Hamilton West, one or two doctors who are present at every game would have been on the scene, as well.

In fact, Steinert head coach Dan Caruso said home football games at any of the three Hamilton schools are never scheduled for the same time because the physicians are required to be there and sometimes have to travel to and from different schools.

Coaches, while trained in CPR, heat illness and concussion protocol and symptoms, hand all medical decisions over to the doctors and trainers onsite. Officials have a similar role—if they think a player is hurt or concussed, they pass that information along to the coach or trainer.

Coaches have no say in whether or not a player returns to the game—medical staff determines that based on tests, though county coaches do take part in injury education at the start of each season and often do their own research to keep themselves up to date.

“Sometimes the trainer might be dealing with one kid and something else happens,” Caruso said. “If something very serious happens, you have a doctor there to take care of it. I think it’s a great thing that the district does for us. I hear stories about back in the old days when it was just a coach out there. That takes a lot off my plate when I can really just worry about coaching.”

Steinert is unique to local schools in that a hospital, Robert Wood Johnson, is directly across the street from the football field.

“We’ve had issues, nothing life threatening, but I can remember a time we had a young man from another school break his leg,” Caruso said. “They were here in a minute, minute and a half. That is really beneficial. If you’re out in the middle of nowhere, it’s going to take awhile.”

And that’s exactly what happened in the case of Cam’ron Matthews, a player from Texas who died after a seizure suffered shortly before halftime during a game this season. Because of the school’s rural location, doctors waited 20 minutes for an ambulance before being forced to call for a medical helicopter, according to a report by the Jacksonville Progress, a local newspaper. The cause of death has yet to be determined.

At Ewing High School, an ambulance is stationed at all games, said athletic director and West Jersey Football League president Bud Kowal. Ewing, he added, is fortunate to have enough vehicles that one can be stationed at the team’s weekly games. Not all towns have the ability.

That ambulance was put to good use during a game in October when a Northern Burlington opponent was injured, requiring the ambulance to actually drive onto the field, secure the player and put him on a stretcher.

Kowal said he and Dan Csillan, Ewing’s athletic trainer were able to decide what needed to be done quickly, and that’s not uncommon for the duo in injury situations. Csillan is in his 24th year at Ewing, and Kowal is in his 12th.

“One good thing is that I’ve been around here a long time,” he said. “The trainer has been here for awhile. We kind of know by now how serious a situation is. We’re able to determine that between each other. We know right away, and more often than not, it all works out.”

Quinnette, in her third year with Nottingham, said fast action is vital.

“We get to them fairly quickly, but we do need time to evaluate the injury and determind whether it is something that is minor enough for them to go back in or serious enough for them to stay out,” she said. “With an ankle sprain in particular, if a kid says there’s a tweak and they pass all of the functional tests, then normally, we can support their ankle.”

Sometimes, though, determining the severity of an injury depends on the player’s honesty. Caruso, Adams and Kowal acknowledged that, although it’s easy to determine when this happens, athletes sometimes try to hide their injuries to avoid coming out of the game, or long-term recovery time.

For most injuries—concussions, sprains, tears, etc.—players need to be symptom-free for one week before they can even begin the return-to-play protocol, which usually starts with running, moves on to drills and non-contact practices, continues to contact practices and, finally, game play. All told, that part of the protocol generally takes five days, though it depends on the injury and the player. It’s a thorough process, and every action of the athlete related to recovery is mapped out until he or she is fully healed and ready to return to play.

“A small injury can become much more serious if it’s not treated,” Kowal said. “We’re not going to keep anybody out that shouldn’t be out, and that is their fear. Would you rather be out for a week, or for the whole season? That’s something we try to cover, not just at the beginning of the year, but in discussions between coaches, the athletic trainers, and the athletes.”

Dr. Rosemarie Scolaro Moser, director of the Sports Concussion Center of New Jersey and author of Ahead of the Game, a parents’ guide to concussions in young athletes, said players have their reasons for hiding injuries. They also need to understand that their livelihood is more important than the game.

“Maybe they didn’t think it was a concussion, or they didn’t want to let their team down,” she said. “There is that pressure, not only in football, when perhaps college recruitment is dependent on athletic play. Athletes want to avoid reporting symptoms, and parents are feeling that pressure, too.”

Caruso said parents play a major role as far as alerting the coaching staff to any injuries or concerning behavior they may notice at home.

Parents, said Moser, are generally involved in injury prevention—all 50 states have concussion laws, and part of that law is to educate parents, who in New Jersey are required to sign an informed consent form about the risks of concussions. Moser suggested taking it a step further and introducing mandatory seminars and other educational tools, like a “back to school night” for parents of student athletes.

“I’ve given programs at schools, but they aren’t usually mandatory or mainstream,” she said. “The problem is that when someone has a child who has concussion, it’s like, ‘Why didn’t anybody tell me?’ People sometimes don’t want to think about it until it happens to their child. If schools include mandatory courses for coaches, why not parents? It can be broader. It doesn’t only have to include concussions.”

Outside of games, Adams limits the time spent in pads at practices and never runs conditioning drills in full gear. Educating parents, athletes and the coaches themselves prior to and during the season is another key part of local programs and those across the country.

But there is a gray area as far as invisible, undetectable or unknown ailments go. According to reports, Murray had an abnormally enlarged spleen, which ultimately made him more vulnerable to the laceration and internal bleeding that caused his death.

Sudden cardiac death, which is covered locally in all preseason packets and on many school websites, is another cause of death that, though rare, often carries symptoms that are ignored willfully or involuntarily. Dizziness, lightheadedness, shortness of breath or heart palpitations during exercise are all quite common, but they can indicate an increased possibility of sudden cardiac death.

The risks that come with playing football, though, can never be totally eliminated, said Moser. As the discussions around concussions and chronic traumatic encephalopathy—especially surrounding the NFL—continue to rightfully gain traction, she said a growing number of parents are pulling their kids from football, and some high schools across the country are shutting down their football programs altogether.

Instead, she offers eight suggestions to keep those risks minimal, especially when it comes to concussions: provide concussion education, instill zero tolerance policies, utilize state of the art skill development, access medical support, carefully use sports equipment, reduce risky athletic exposure (only necessary practices, reduce the amount of contact in practices, etc.), believe that youth sports are not professional sports and treat every concussion carefully and thoroughly.

“These are just kids,” Kowal said. “They have 60, 70 years of life left, if not more. We certainly take every precaution we can.”