Article Link: Sideline Doctors Face Scrutiny After Hits to a Star Quarterback - The New York Times (nytimes.com)
The sidelines at N.F.L. games are better staffed than many emergency rooms. There are orthopedists, neurotrauma specialists, athletic trainers and even an “emergency airway intubation” specialist. In the press box, medical experts scan the field to spot any potential head injuries that might have been missed below.
Yet for all its medical firepower, the league is again under scrutiny, this time over how some of those doctors diagnosed a head hit to quarterback Tua Tagovailoa of the Miami Dolphins two weeks ago. After holding his helmet, struggling to get up and falling again, Tagovailoa was taken to the locker room, examined and allowed to return to that game.
The N.F.L. at first said that the Dolphins team doctor and unaffiliated neurotrauma consultant who evaluated Tagovailoa had followed established protocols. But the N.F.L. Players Association initiated a joint investigation into the incident and, after Tagovailoa suffered an even bigger head hit in a game four days later and left the field on a stretcher, the union, in an unprecedented move, dismissed the unaffiliated consultant.
The episode has shined new light on the doctors tasked with caring for the players and the protocols they must follow when diagnosing potential brain injuries.
Experts in brain injuries say that there remains no objective tool to identify a concussion and that many symptoms occur hours and even days later, two factors that complicate doctors’ decisions about whether to pull a player from a game. Elite athletes can often handle the physical tests designed to gauge their balance and motor skills. And even players who are disoriented may be able to pass the cognitive tests.
“People have this idea that N.F.L. players are dumb, but they’re not,” said Uzma Samadani, a neurosurgeon who was an unaffiliated neurotrauma consultant for four years at Minnesota Vikings games and developed an eye-tracking device to more definitively diagnose concussions. “Many players can pass this test even if they’re concussed.”
The league and players union are still reviewing the process followed after Tagovailoa hit his head in a game against the Buffalo Bills on Sept. 25. But because of the incident, the league and union said they were considering changing the protocols, which currently allow a player with “gross motor instability” to return to the game if doctors decide there is an orthopedic reason for his unsteadiness. The expected change will be to instead establish ataxia, a term describing impaired balance or coordination caused by damage to the brain or nerves, as a sign that automatically disqualifies a player from returning to the game.
The change is intended to prevent situations like Tagovailoa’s, in which doctors judged that he stumbled and fell because of back and ankle injuries, not a head hit, and sent him back in.
“It’s more aggressive in protecting the patient,” said Thom Mayer, the medical director of the players union. “And it’s pretty hard for people not to understand the term ataxia, as long as they have a background in caring for head injury patients.”
On Friday afternoon, the union urged the league to agree to the new protocols. “We would like these changes to go into effect before this weekend’s games,” it said in a statement.
But this tweak does not address who makes those calls.
According to the protocols developed by the league and union, the responsibility for the diagnosis of a concussion and the decision to let a player return to the game “remains exclusively” with the team doctor. Most members of team medical staffs — and every head team doctor — are orthopedists or primary-care sports-medicine doctors. Allen Sills, a neurosurgeon and the N.F.L.’s chief medical officer, said when the head team doctor does not have experience evaluating and managing brain and spine injuries, a doctor who does takes on that responsibility.
“The person who is making the final call for the team is always going to be someone who has expertise and training in the field of concussion management,” Sills said.
This person may be an internist or family-medicine doctor with a sports-medicine certification. While clubs must retain a neurological consultant and a consulting neuropsychologist to help care for players, these specialists do not have to be at games. The Denver Broncos and Pittsburgh Steelers are among a handful of teams who have taken the extra step of having a team neurosurgeon on their sideline for both home and away games to evaluate brain injuries. “My father and Chuck Noll both knew the importance of having a neurosurgeon to help with any issues,” the Steelers’ owner Art Rooney II said of the team’s long practice.
Vernon Williams, the neurologist for the Los Angeles Rams and director of the sports neurology center at the Kerlan-Jobe Institute, cares for Rams players during the week if they have a concussion or other neurological issue, but he is not with the team for games. He said the most important criterion for doctors making in-game diagnoses was extensive experience evaluating signs of acute concussions, which doctors in many different specialties can have.
“I couch that by saying, the brain is what the neurologist does all day, every day,” Williams said. “So neurologists, neurosurgeons, I think are ideally suited.”
To provide team doctors with more objective assessments, the N.F.L. in 2012 began the unaffiliated neurotrauma consultants program that put an expert on each sideline — and, later, a third upstairs in the booth — who was credentialed at a local trauma center and not on the team payroll. More than 80 percent of the about 200 consultants are neurologists or neurosurgeons, according to Sills, though they are not required to be. The consultants are jointly paid by the league and the players association, and both parties must approve them after they are vetted for basic criteria, such as treating patients with acute head injuries at least once a month.
It can be hard to find experts willing to take on this role, which requires working on days off for relatively nominal compensation. Jack Wilberger, an emeritus professor of neurosurgery at Drexel University, served as a consultant at Steelers games for about three seasons but stopped because of the long hours on the sideline, often in bad weather. The working conditions are “chaotic,” he said, because of the commotion in the stadium and players who may be anxious about being taken out, leading to “terse” evaluations.
The consultants assist and offer input as the team doctor evaluates players, and they submit their own reports after the game detailing each concussion screening. Sills said that team doctors and the consultants have differed in their assessments fewer than once per season in his five years as chief medical officer. He was not aware of any cases during his tenure in which a team doctor overruled a consultant so a player could return to the game. The players union confirmed this.
Samadani said she could not recall a time when she disagreed with the Vikings’ medical staff when she was a consultant on the home sideline. But, she said, opposing team doctors were sometimes less receptive to her opinion.
Wilberger also recalled being in sync with the Steelers’ neurosurgeon. But he said that one flaw in the program was that the game-day neurotrauma consultants received no information on how the player was doing after the initial evaluation, unless the doctor was also the team’s designated consultant for return-to-play decisions during the week, a separate role.
“Obviously, we try to make things better each time we do it, but then we find out things like this happened and somehow slipped through the cracks,” Wilberger said, referring to the handling of Tagovailoa.
It’s not unusual for an N.F.L. player to appear disoriented or unstable after a hard hit. In the first quarter against the Broncos on Thursday night, Colts running back Nyheim Hines’s helmet collided with a defender’s on a tackle. He slowly climbed to his feet but was wobbly and needed help to remain upright. He was immediately removed from the game and was later ruled out with a concussion.
In a game Sunday night between Tampa Bay and Kansas City, Buccaneers tight end Cameron Brate’s head collided with the torso of his teammate, Chris Godwin, while Brate ran a route in the second quarter. Brate lay on the field momentarily before slowly rising and jogging off.
He returned a few plays later and finished the drive, but was taken out of the game at halftime with a concussion. Coach Todd Bowles said afterward that Brate had complained of shoulder discomfort and that “nobody called down” to hold Brate out. But after complaining of concussion-like symptoms in the locker room, Brate was placed in the concussion protocol.
Still, the situation led some to question if the N.F.L. had learned from the handling of Tagovailoa’s injury.
“Broken system,” Tony Dungy, the former Colts and Buccaneers coach and current NBC commentator, wrote on Twitter. “I was on the sideline very close to Brate — obvious he had his bell rung. There’s a league-appointed spotter in the press box who should stop play & alert the referee. Brate shouldn’t have been allowed to return until after an evaluation. Why didn’t that happen???”
Ken Belson covers the N.F.L. He joined the Sports section in 2009 after stints in Metro and Business. From 2001 to 2004, he wrote about Japan in the Tokyo bureau. @el_belson
Jenny Vrentas is a sports reporter, working on enterprise and investigations. Prior to joining The Times she was a senior writer at Sports Illustrated, covering the N.F.L. @JennyVrentas
Emmanuel Morgan covers sports, primarily the N.F.L. He previously reported for the Los Angeles Times, where he covered both local N.F.L. franchises, writing features on players, personnel and on-field trends. @_EmmanuelMorgan