The moment Marissa Slavin tripped and banged her head hard on the court in a Pennsbury middle school basketball game, nearly every person inside the gym could see that something was very, very wrong with the then-12-year-old.
Everyone except her coach.
"He didn't see her fall," recalled her mother, Mary Ann Canzano. Marissa, now 15, said she blacked out for a couple of seconds but the coach was already watching the other players race up the court.
"There's Marissa, very slowly getting up, trying to jog up the court, but she can't," said her mother. "It was like her legs were rubber."
Taken out for a while to recover, Marissa was back in before the game was over.
The talented young point guard from Yardley played again the next week, and later with her travel team, despite headaches, memory problems, and mood swings, until a neurologist finally diagnosed her with post-concussion syndrome.
On Sunday, a new law took effect in Pennsylvania to ensure Marissa's experience is not repeated. The measure, signed in November by Gov. Corbett and called the Safety in Youth Sports Act, marks a sea change in how coaches, school officials, athletes, and parents are to respond to head injuries to school-aged athletes - injuries that are increasing from the soccer field to the cheerleading pyramid.
The new law is a response to an alarming rise in reports of traumatic brain injuries in high school and middle school sports. One national study found that emergency-room visits for concussions in young athletes doubled from 1997 to 2007; locally, the Central Athletic League in the Philadelphia suburbs found its 12 high schools documented 223 concussions in the 2010-11 academic year. Among those were 70 football players, 18 female soccer players, and nine cheerleaders.
The new law requires that athletes suspected of suffering a concussion be immediately removed from play, bars them from returning until cleared by a physician, and penalizes coaches who don't follow the rules. It also requires yearly training in concussions for high school coaches, while parents must sign an information sheet on brain injuries.
Changing the win-at-all-costs attitude of some schools may be harder.
"Unfortunately, you have a lot of young coaches, inexperienced coaches, coming into the arena with these responsibilities," said Bob Buckanavage, executive director of the Pennsylvania State Athletic Directors Association. "Their primary purpose is to win. That's a landscape that will never change."
But others say the culture has changed.
"From the top down," said Michael Friel, athletic director at Radnor High School. "Parents are very involved and kids are much more aware of it. Fifteen years ago when I was playing, we did go back in."
Some still do. Case in point is Haley Mankin, who was a Radnor High School sophomore last year when her cheerleading squad pyramid collapsed at a competition and she took three hits to the head. She stayed and finished the last routine before leaving in tears.
"I don't think anyone understood the magnitude of it," said Mankin, now 17 and still suffering post-concussion migraines.
Neither she nor her coach recognized the symptoms, she said, and she didn't want to tell her parents for fear they would make her quit.
Mankin thinks student athletes need to recognize when they're hurt and take themselves out of the game.
"I know it's hard," she said. "In high school, sports sort of become your identity."
On the eve of the law, both schools and doctor's offices have been gearing up - enrolling coaches in online concussion-training programs, stepping up tests for student athletes that establish a baseline on brain activity, and in some cases making changes on the playing field.
Strath Haven High School, for instance, is now requiring female soccer players to wear helmets.
"It definitely lessens an impact, so if girls collide or head a ball, they will be safer," said principal MaryJo Yannacone.
Schools must also make academic accommodations for students diagnosed with concussions. Treatment is often a week or two of downtime at home so brains can relax. But if symptoms persist, schools must provide homebound instruction.
Some health-care centers are bracing for an upsurge in patients as a result of the law. Matthew Grady, sports-medicine specialist at the Children's Hospital of Philadelphia, said its area facilities were seeing 50 concussions a week last fall; now they're adding a fourth sports-medicine specialist to deal with what he expects will be "an onslaught."
"We think this law really raises the bar for recognition of concussion and making sure that we get appropriate management early on," Grady said.
Lou Sudholz, athletic director at Pennsbury High School in Bucks County, agreed.
"The days of 'How many fingers do I have? . . . OK, you're good,' and sending them back in are over," said Sudholz. But Sudholz also said students "need to be their own self-advocate. They took a shot, they're not feeling right, you've got to take a look at me."
Slavin said she was reluctant to stop playing, even after hitting her head on the court two months later, and then a month after that getting elbowed in the head - her third concussion.
"We started noticing that my memory started to go," Marissa, now a Pennsbury High School sophomore, recalled. "I would get to somewhere and wouldn't remember how I got there."
Remarkably, she kept up her A average in school, but also grew noticeably anxious and irritable, and even began falling asleep in class. Finally, in eighth grade, her parents took her to a neurologist who diagnosed her with post-concussion syndrome and prescribed a standard cure.
For two weeks, Marissa stayed out of school in a darkened house with no TV, computers, or video games. She slept most of the time, and at the end "it felt the fog kind of lifted." Not only did things gradually get better in school, but she eventually resumed some sports - even taking part in noncontact basketball practices.
Her mother, Canzano, said the new law and increased awareness would certainly help, but she struggles every day to balance a daughter's love of sports with the potential risks.
"She wants to play a sport, and we try and make it as safe as possible," she said. "If Marissa hits her head one more time, she's done."