The only video allowed on the sidelines during an NFL game is the Injury Video Review System, which runs on a flat-screen Tru-Vu monitor and is controlled by an Xbox remote. Coaches must rely on photographs in order to make in-game adjustments, but reviewing actual replays is a mandatory part of the league’s concussion protocol, offering the team doctor and unaffiliated neurotrauma consultant (UNC) more insights about the mechanism for injury—that is, the potentially concussive blow a player suffered.
The system is stored in a black cart that’s kept next to the blue medical tent where physicians conduct sideline exams. Clad in a red hat for easy identification, the UNC holds a Microsoft Surface tablet and reviews the player’s symptoms, checking off boxes in a concussion assessment app from C3 Logix, a spinoff from the Cleveland Clinic. The physician checks the athlete’s pupils, coordination and speech and asks the Maddocks questions, a series of queries designed to check for confusion or amnesia. The tablet also provides access to electronic medical records to assist with the evaluation.
“Right now, we do three negative exams for every one that’s positive,” says NFL chief medical officer Dr. Allen Sills, speaking on the sidelines at MetLife Stadium before last Monday nights game between the Patriots and Jets. “That’s a ratio that we’re very comfortable with. We want to have a wide screening net.”
Even those not diagnosed with a concussion will continue to be tracked throughout the game, and they are required to receive a follow-up checkup the next day, given the potential for delayed onset of symptoms. Players suspected of having a concussion enter the locker room for a more thorough neurological exam.
The UNC and team physician collaborate on evaluations, and either one has the sole power to declare a player ineligible to return. (Sills, however, says there is usually only one disagreement across the NFL each season.) While the intention of the UNC program is to ensure independent decision-making, the league believes working in tandem provides the best care. “Sometimes the only sign or symptom of a concussion is a personality change,” Sills says. “That can be very subtle. If you don’t know the player, you would have no way of knowing that.”
The pop-up blue tent offers increased privacy and fewer distractions—important given how much of the concussion exam depends on visual concentration. The tent can accommodate as many as 10 people, although typically about half that number go inside. No coach is permitted to intervene in the process or even enter the tent. “That is a substantial culture change from not very long ago where the medical staff has authority,” says Jeff Miller, the NFL’s EVP of health and safety.
In a booth high above each NFL stadium, a second UNC watches the action along with two certified athletic trainers, serving as spotters for possible injuries. The spotters watch each play, often with binoculars, and then have two TV screens showing the action on differing delays. There are also two video technicians assisting with reviews, and a direct line to the medical staff on the sideline. “We can really triple-check if we see something,” says ATC spotter Robb Rehberg. “Communication is the key here.”
The booth personnel can help direct sideline practitioners to assist players who may have suffered an injury undetected at field level. They can even call a medical timeout to require a player to receive medical attention; 11 such timeouts have been called so far this season. Communication systems have triple redundancy: headsets, team medical radios and sideline telephone lines.
In all, a minimum of 31 medical personnel work each NFL game, whether it’s preseason, regular season or postseason, including three UNCs (one on each sideline and one in each booth) and an airway management physician who specialize in emergency intubations. They gather an hour before kickoff along with the head and assistant referee to “set the tone,” Sills says, in emphasizing player welfare and also making important visual identifications of personnel. Every road team receives a Visiting Team Medical Liaison who can help coordinate tests and exams with the local medical system. Each stadium and practice facility has its own X-ray lab and its own Emergency Action Plan, including the international games, for serious injuries.
“You see doctors and trainers run out [onto the field], but that’s the tip of the iceberg,” Sills says. “There’s an enormous amount of resources that goes into the care of the players during the game.”