Boston Globe: Here’s how the NFL’s concussion protocol really works

Mar 08, 2018

INDIANAPOLIS — Dr. Allen Sills wishes there were an easy solution to diagnosing concussions.

“We’re not at the point where a player would come off, get a blood test, and we say, ‘Yeah, you have one or you don’t,’” said Sills, a neurosurgeon at Vanderbilt and the NFL’s chief medical officer. “Boy, that’d make our job a lot easier, right? But we’re not there yet.”

The NFL hasn’t figured out yet how to prevent concussions, either. The league reported 281 concussions during the 2017 season, up from 243 the year before.

“We’re not going to be satisfied until we drive that number much lower,” Sills said.

The NFL still has its share of concussion controversies — including Tom Savage and Russell Wilson last season — but it no longer ignores the problem. The league strengthens its concussion protocol each offseason, and last week at the NFL Combine, it voted to add a third unaffiliated neurotrauma consultant (UNC) at each game, one to sit in the press box and monitor the TV broadcast.

The NFL’s concussion protocol, first introduced in 2009, has morphed into a standardized system combining video technology, internationally recognized standardized testing, and a team of neurotrauma specialists and athletic trainers to diagnose and treat potential concussions as quickly as possible.

Last week at the combine, Sills and the NFL gave the Globe a behind-the-scenes tour of the Colts’ medical facilities at Lucas Oil Stadium, and a soup-to-nuts demonstration of how the protocol works. The NFL emphasized that the facilities are similar in all 31 stadiums (plus London and Mexico City), and the protocol is supposed to be followed exactly the same way every time.

Before the game
Last season, the NFL formalized a new pregame meeting that takes place an hour before kickoff involving the referee and all game-related medical personnel.

There are approximately 30 medical personnel on a game day, including each team’s doctors, three UNCs, two concussion spotters (ATC spotters), paramedics, local EMS, an airway management physician (who can intubate a patient), an eye doctor, a dentist, and a visiting team medical liaison, usually a local physician who meets with the visiting team and helps coordinate any medical needs. The ATC spotters were added to the press box in 2012, and the UNCs to the sideline in 2013.

At this meeting, they go over the Emergency Action Plan and all of the different scenarios that can play out during a game. Every stadium is required to have an EAP, and teams must simulate all the scenarios before each season.

“What hospital are we going to go to? Where is the X-ray located? Where is the ambulance, the spine board, the Level 1 trauma center?” Sills said. “We want the referee to have a visual ID of who’s who in the emergency-care chain.

“It also gives a chance for the independent personnel to visit with each other and do radio checks, and then also cover how the ATC spotter will communicate to the referee when they need to stop the game.”

Games in London and Mexico City have double the personnel (other than the UNCs and ATC spotters); the teams bring their own medical staffs, and the NFL provides a local staff.

“We make sure that the level of care that’s available both in stadium and in the hospital is equal to anything we have in the States,” Sills said.

Eyes in the sky
Each sideline has hundreds of eyes watching every play (players, coaches, doctors, etc.), constantly looking for players who are concussed or otherwise injured. But with so much going on during the course of a game, sometimes injuries don’t get noticed right away.

That’s why the NFL stations four experts in a quiet booth in the press box: two ATC spotters, a UNC (a neurosurgeon or neurologist), and two video technicians. Last season, the NFL had a UNC in its replay studio in New York City, but “the feedback was it’s very difficult for one person to see nine games at one time,” Sills said.

The third UNC on site is a direct result of the Savage concussion from December, when most of the medical attention went to another player who looked to be more severely hurt. The Texans quarterback initially passed a concussion test on the sideline and returned to the game, but later showed more symptoms and was removed.

The NFL did not penalize the Texans, as Sills said the doctors on the field didn’t have a great view of the play, and that symptoms didn’t manifest immediately. Adding the third UNC and having him monitor the TV broadcast from the press box should help fix that.

“The idea is giving them sort of the 30,000-foot view of the field,” Sills said. “Just remember, in real time, the docs on the sideline are trying to examine the player. The doc on the sideline doesn’t just sit there and stare at the monitor for 20 minutes. It’s very hard to see a lot of this stuff in real time, and even some of the replays are not that helpful for what you really want to see.”

The ATC spotters are certified athletic trainers who work mostly in college sports. They are local, and a pool of the same ATC spotters work every game at one stadium. For competitive reasons, the NFL has a rule that to be an ATC spotter, a person can’t have worked for any NFL team within the last 20 years.

Inside the booth are two video monitors, each hooked up to its own laptop — one for the home team, and one for the away team. Each TV has a live feed of the broadcast, and the ATC spotter is constantly communicating with the video tech (“Can you rewind that last play?” “Can you zoom in on 74?” “Is there a different angle?”).

The video tech has access to every camera angle provided by the network broadcast. And the tech can work on home team video while the away team is still viewing the game live, or he can work both systems at once.

The ATCs and video tech also are communicating via headset with the medical personnel on the sideline, sending videos down to the doctors to review. The doctors and the UNC on the sideline, wearing noise-canceling headphones, also will call up to the booth and request video.

For any potential injury — even a minor ankle twist that forces a player out for just one snap — the video tech tags the play and logs it for quick access later. After the game, the video tech will put all of a team’s injuries on a thumb drive, and the medical staff can view it on the flight home.

All injuries also get logged into a tablet and immediately are entered into the player’s medical record. At the end of each game, the ATC spotter files a medical report via the tablets that go straight to Sills and the NFL.

“And we can go back and track exactly when a player was injured and who he talked to,” Sills said.

The ATC spotters can also communicate directly with the referee, and since the 2015 season have been empowered to stop the game to remove a player for a medical check, concussion or otherwise. Sills said it happened five times in 2017.

“The athletic trainer up here is the only medical professional we know in the world that can actually stop the game for medical concerns,” Sills said. “They certainly take that responsibility very seriously.”

On our tour, the NFL used an example of Texans quarterback T.J. Yates in Week 17 against the Colts. He took a safety late in the fourth quarter, and two TV angles didn’t raise any red flags. But a third angle, taken from the end zone, showed Yates getting slammed head-first into the turf. The booth called down to the sideline, instructed that a concussion test be done, and Yates subsequently passed all tests and was allowed to return.

Anyone who is given a concussion test during the game must also be given one the next day, which Yates passed, as well. But it is not uncommon for a player’s concussion symptoms to first appear hours or even days after a game.

“Despite all the technology and the sophistication, it’s still not an injury that’s able to be diagnosed 100 percent of the time immediately,” Sills said.

Privacy on the sideline
While the ATCs and video tech are communicating down to the sideline, the doctors are tending to the player on the field. If a player shows a loss of consciousness, signs of amnesia, or the “fencing” position (arm extended), he is immediately ruled out for the rest of the game.

But for less severe hits, the player is brought to the sideline and taken into a pop-up tent for a private examination. The tent is roomy, with seven or eight doctors able to stand around the examination table.

Coaches and non-medical personnel are forbidden from entering. Anyone who gets a “stinger” also is required to get a concussion evaluation.

The NFL made it mandatory in 2017 to do the sideline test in a pop-up tent to eliminate “visual distractions.”

“One of the important things about doing a concussion exam is I need attention and focus, because that’s part of what I’m testing,” Sills said. “It’s amazing how much calmer everybody is in here.”

Each sideline has an Injury Video Review System with which doctors can watch video of an injury that is being fed from the press box. Each sideline also has a technician to help the doctors with the video, and noise-canceling headphones.

Meanwhile, two doctors will give the player a preliminary test inside the tent — the UNC, who is appointed by the NFL’s head, neck, and spine committee and approved by Sills and the NFL Players Association, and a team doctor. Sills said it is important to have someone who knows the player.

“Sometimes the only symptom of a concussion might be a personality change,” Sills said. “That’s why we think it’s an advantage to have this team approach — an independent person who hasn’t seen the person every day, and someone who actually knows them, and we can put heads together.”

In the preliminary sideline test, the doctors will look for red flags (neck pain, double vision, vomiting), test the player’s gait and vision, test the player’s neck and spine, and ask “Maddocks Questions,” a set of five that includes, “What venue are we at today? Which half is it now? Did your team win the last game?”

The initial test usually takes up to five minutes, and if a player passes everything with no issue, he can return to the game.

Giving the test is also a collaboration between teams. If a UNC is preoccupied with a concussion test, the UNC on the other sideline can tend to another player down on the field. Otherwise, the players just have to wait until the UNCs are free before they are tested.

But just because a player passes a test doesn’t mean the doctors are done observing him.

“This isn’t a one-and-done thing,” Sills said. “I’m going to watch him during the next set of plays, see how he looks, and probably walk up to him after the series and say, ‘Hey, are you OK?’ ”

In the locker room
If a player displays signs of a potential concussion, he is brought back to the locker room for further testing. The doctors take the player’s helmet away, and don’t give it back to him unless he passes all testing. Coaches and other team personnel are not allowed to join them.

In the locker room, the player is led into a small, quiet examination room, where he is given the SCAT5 test — a standardized exam developed by the international Concussion In Sport Group in April 2017 and immediately adopted by the NFL.

Over 10-15 minutes, the doctors go through a series of background questions, a checklist of 22 symptoms with a score from 0 to 5, a cognitive screening, an immediate memory screening, a concentration screening, a balance exam, and a delayed recall test five minutes after the immediate memory screening.

The doctors use a tablet to give the exam, and log the answers electronically.

Some of the questions are basic: “What month is it? What time is it right now? Can you recite the months in reverse order?”

The memory and concentration tests aren’t so easy. The doctor gives a list of five words (e.g. “finger, penny, blanket, lemon, insect”) that the player must recite back, and they go through five or six different lists. Then they graduate to 10-word lists. The doctor will then read a series of numbers to the player, and the player must recite it backward: “6-1-8-4-3” becomes “3-4-8-1-6.”

All players take this test before each season to establish a baseline. Any player who has had a diagnosed concussion must take a new baseline test before the next season.

After giving the examination, the UNC and team doctor confer on a “go or no-go” decision. The NFL prefers the team approach, especially since the team doctor knows the player well.

“There has to be clear consensus,” Sills said. “If there’s any hesitancy whether someone is normal or not normal, they’re going to keep him out.”

If a player is ruled out, he must remain in the locker room for the rest of the game. Someone on the medical staff will stay with him to monitor his condition. The player will be tested again later that day, and again the next day and until he clears the concussion protocol.

This strengthened approach helped the NFL diagnose 281 concussions last season. But even the NFL concedes it is not perfect.

“The biggest challenge is it’s an injury where you have to rely on someone to tell you their symptoms to diagnose,” Sills said. “We don’t have a test yet that’s definitive. So until we are there, we will try to build the very best system that we can.”

Who’s who in the concussion protocol
In the press box:

2 ATC spotters – have the power to stop the game

1 Unafilliated Neurotrauma Consultant – monitoring the TV broadcast

2 Video technicians – feeding video to the ATC spotters and the sidelines

On each sideline:


1 video technician

4-5 team doctors

Giving the tests

1 UNC – providing an unaffiliated medical opinion

1 team doctor – providing an informed opinion of the player’s personality

*Both must agree without hesitancy for a player to return to play.

By Ben Volin for the Boston Globe