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Protocol breakdowns prove NFL concussions problem not improving

The NFL said they would improve their concussion protocol after coaches and trainers missed Colt McCoy's head trauma. But in the wake of recent incidents, has anything really changed?

On Dec. 8, 2011, Browns QB Colt McCoy took a vicious, illegal hit to the head by Steelers linebacker James Harrison during a 14–3 loss to Pittsburgh which left him lying prone on the field. But instead of having McCoy head straight to the locker room to undergo a concussion test, then-coach Pat Shurmer and the rest of the medical staff deemed their QB fit to return to the game after just two plays.

In fact, when McCoy came to the sideline, the team trainers and doctors mostly focused on his bruised hand. In a later press conference, then-team president Mike Holmgren said McCoy was complaining about his hand while on the sidelines; in contrast, McCoy later said he couldn't even remember the hit. The Browns didn't even give McCoy the standard SCAT concussion test until the next morning—after McCoy requested that the media turn off their flashes in the post-game press conference, since sensitivity to light is a prominent symptom of a concussion—and of course, that test showed abnormal results.

“We followed all the proper medical procedures,” Shurmur said about the decision to put McCoy back in the game, and whether he was given any concussion tests on the sideline. “I don't know what got reported other than what you're telling me now, but we followed all the proper medical procedures and that's where it's at … There's a process that you go through when he has concussion-like symptoms. The specifics of that are probably better asked to our medical people.”

Holmgren defended the Browns' staff in what was eventually deemed by an NFLPA rep to be “total system failure.”

On Nov. 22, 2015, Rams QB Case Keenum was hammered by defensive end Timmy Jernigan and slammed his head hard on the turf during a 16–13 loss to the Ravens. Keenum was wobbly as he got up, needing help from a teammate to get back on his feet. Backup QB Nick Foles got up off the bench to warm up, but Keenum stayed in the game. Afterward, coach Jeff Fisher said little of the events that led to Keenum staying in the game, and only addressed the issue the next day as “a combination of unusual events that took place.”

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“I saw Case go down, but I didn't see anything else take place. I didn't see him struggle to get up. I didn't see anything from my vantage point on the sideline as far as Case's slow recovery. The shot that you see where he got up slow that we've seen out there, I didn't see that. I was in the game management mode at that point, less than a minute left. That's where I was.”

Team trainer Reggie Scott went out on the field to talk with Keenum during a penalty timeout, and because Scott was speaking with Keenum, the concussion spotter in charge of alerting the sideline didn't feel the need to notify the team staff.

It was total system failure, by any name. Four seasons after the McCoy incident that was supposed to change everything about the NFL's concussion protocol, the NFL seems to be very much at a standstill. The NFL and NFLPA scheduled a conference call with all 32 of the league's head trainers to reinforce the protocol, but the Rams were not penalized in any way for the complete and total malfeasance of that protocol—just as the Browns weren't penalized four years before.

So, what did the NFL learned from the Keenum disaster? Not much. The league had a chance to make it right the week after Keenum's incident, but again, they missed.

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​Steelers QB Ben Roethlisberger experienced a number of hard hits in a 39–30 Week 12 loss to the Seahawks, including one to the head from defensive end Michael Bennett. Roethlisberger clearly took his time getting up after the knockdown, but remained the game. Eventually, he went to the sideline and told his team's medical staff, including neurosurgeon Dr. Joseph Maroon, that he was having trouble with his peripheral vision and it appeared that he was looking through water. Had he not self-reported, it's likely that Roethlisberger would have stayed in the game.

“You can have, when you’re done playing, knee replacements and hip replacements and all kinds of surgeries," Roethlisberger said after the fact. "There’s no brain replacement surgery. That brain is too valuable to mess with. I’m proud of myself and I think more guys should do it and not try to be tough guys when it comes to the brain.”

Steelers coach Mike Tomlin endorsed the move to whatever extent he was able.

“We will do what we always do with those guys, we will be very diligent about their care,” Tomlin said. “We will lean on the expert advice of our medical team, who always does a great job. We will do what is appropriate at the end of the week, or whenever that decision-making time is.”

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Well, let's not forget that Dr. Maroon, a member of the Steelers medical team, went on the NFL Network in March and called the concerns about the links between head trauma and CTE “over-exaggerated,” and said that “there are more injuries to kids from falling off bikes, scooters, falling in playgrounds than there are in youth football. It’s never been safer.”

This is also the same Dr. Maroon who may have helped to sanction too-early returns to the field for Roethlisberger and tight end Heath Miller during the 2014 playoffs—essentially, the players returned to the game without having the time to undergo the standard tests. These are issues separate from refining a concussion protocol, but in the Steelers' case, they might not be so separate.

It would have been tough for the NFL to do a worse job of putting forth the impression that it truly cares about the head trauma-related health of its players, or that it's learned anything from past transgressions.

Who's to blame?

One thing is clear: No matter who you talk to on which side of the subject, nobody wants these head traumas to happen. The NFL of today isn't quite the NFL of 20 years ago, when the medical professionals at the top of the ladder were collectively, shamelessly and unilaterally denying any link between head trauma on the field and long-term problems for players during and after their football lives. (Though there are still too many Dr. Maroons in the league).

There's been a ton of education and awareness work done, and while it was slow to gain traction, there is a relatively massive change in thinking throughout the league regarding concussion awareness in a hypothetical sense. The problem is that the NFL has not yet put things in place for a consistent, lock-step system in which its players are protected. And that's where the holes in the protocol show up.

I spoke with Will Carroll, a renowned sports medicine expert who is the managing editor for FanDuel and has also written for SI, ESPN, Football Outsiders and Bleacher Report, on the most recent Audibles podcast, and when I asked him about the breakdowns in protocol, he pointed to the step-by-step.

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“The difficulty is not in getting people to understand this, which it used to be,” Carroll said. “Ten years ago, it was difficult to get people, especially coaches, to take this seriously. We're pretty much beyond that. What we have is a problem of visibility. Concussions are difficult to see. When Justin Forsett breaks his arm, or Chris Johnson breaks his leg, you see that he is laying down. Doesn't happen with concussions. A guy gets hit? Well, that happens on every play. A guy is a little slow to get up—OK, that happens on a lot of plays. You see a guy who maybe isn't quite right, whose eyes aren't focusing? That's the part—we can't see that. ... Remember what the athletic trainer is doing during the game. Any of them, at any time, could be helping someone else who was hit. They could be taping somebody up, or helping somebody to get back in the game. They could be treating a concussion that happened on the previous play. They're also standing near the bench, behind a wall of giant humans. They don't have multiple camera angles.”

This is where the spotter is supposed to come in. After the McCoy incident and after deciding that the strategy of turning game officials into concussion specialists wasn't going to work very well, the NFL decided to implement the medical spotter (a "neurological spotter," in the league's parlance)—an athletic trainer who has access to replay and can call down to the sideline to alert the team staff and the officiating crew that a player may be concussed.

The NFL has also been saying for years that it would have independent neurologists on every sideline—which they have finally implemented—but as Carroll revealed, that's not really a foolproof plan at this point. It's unclear who pays the neurologists, and he has minimal power when a NFL game is in action. Is the neurologist allowed to consult with the trainers if he sees something the training staff and spotter may not have seen?

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“There's some disclarity on that,” Carroll said. “In the original [protocol], he couldn't have. But this has developed over time. I have a feeling that there's enough professional courtesy and concern that if Dr. Smith, the independent doctor, saw something happen, he would yell over to Dr. Jones, the team physician, and say, ‘Hey—did you see Keenum's head?’ And the team doctor may say, ‘No.’

“Again, this is not a problem of intent. And where [the Keenum case] particularly seemed to have been thrown off was that Case Keenum walked to the sideline. The spotter has reported that he did not hit the button to stop the game, because the head athletic trainer came out during the penalty timeout. He said a couple words to Keenum. Now, if you see the athletic trainer talking to the player who was just injured, it's a reasonable assumption to think, ‘Hey, he saw that happen, and he's now checking on the situation.’”

And then, the question becomes, why didn't the head athletic trainer give Keenum the standard SCAT test based on what he observed? Which is the exact same question everyone was asking when the Browns underwent ‘total system failure’ in Dec. 2011.

What can be done?

To be fair to Fisher, or Shurmur, or any other coach out there, expecting them to diagnose concussions when they're dealing with tens of other things at any given time is a bit specious. I asked Vikings coach Mike Zimmer about his thoughts on his own team's concussion awareness, and he talked more about the overall recovery process.

“I think it’s very, very important for the NFL, to the NFL that we continue to keep players healthy. They’re really the livelihood of our game. I think they’re doing everything that they can, the research, trying to keep guys healthy. I know here, with the Vikings, we’re committed to keeping our players healthy. We’ve added recovery rooms, we’ve added a number of other modalities to try to help the players get refreshed, get back on the field quicker. I think it’s extremely important for the NFL.”

And does the current system work?

“I don’t know. I’m just a football coach. I just do what they kind of tell me to do, to be honest with you.”

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Most coaches, if pressed, would likely tell you that they feel this way. They aren't evil men trying to hide a false protocol. They have many other things on their plates. Instead, those in charge of the process must be held accountable for this to work. And those in charge of the process must be given real and authentic authority to press change right when it needs to happen: On the field, the second a player goes down, and struggles to get back up, with a head injury.

Eric Winston, the starting right tackle for the Bengals, a 10-year NFL veteran and the president of the NFLPA, believes that the league may not get its act in gear until teams are specifically disciplined, just as the players are, for violations of player safety rules.

“I think we've put a lot of protocols in place,” he told me. “I think we've made improvements in the last four years. But I come back to the simple fact that players are professionals. The coaches are professionals. The people who work on the medical side are professionals. They should be, and they're supposed to be, at the top of their game, like the players are. From the very beginning of this health and safety... I don't really even know what we're calling it... but this revolution in a way of taking hits out of the game and not launching and everything we've done, the players were asked [to change]. And in many ways, the onus has been put on us, to change the way we play. And a lot of it is for the better—it's for the health of each other, short-term and long-term. When we fail to live up to that, we're fined. We're disciplined, to try and change that behavior.

“The problem I see is that there's only one group of professionals getting disciplined for this. Not everyone else is held accountable for their actions. That doesn't mean that these are bad people. We're trying to correct the behavior. But that's the problem I have with it. One side gets a talking-to, and the other side gets fined. That's not okay—everyone's got to be held to the same standards. Everyone is in the same boat together. Or, we're supposed to be. That's where a lot of players scratch their heads and say, 'Oh, it's just the typical league again.’”

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When the NFL disciplines players at a higher level than it disciplines teams or officials, players have every right to be cynical about the process. But cynicism won't solve this. It won't get the Colt McCoys and Case Keenums and Ben Roethlisbergers of the future (quite probably the near future) off the field and out of the game when they need to be out. Only through a tacit understanding of the realities and complexities of the situation will this ever improve. And it has to improve—for the good of the game, and especially for the good of players who have been seen as disposable too often for far too long.

Winston spoke to the heart of the problem when I asked him how he would like to fix things.

“I always look at it and say, ‘Okay, let's get the experts in the room.’ I can tell you from my perspective—this is what I see. Maybe we should do this or that. The neurologist will say, ‘Well, actually, you probably want this here.’ A coach might say, ‘This here or this here.’ The trainer might say, ‘Well, actually, you can just combine those.’ That's what constantly needs to happen. A lot of people feel like there are gaps in this protocol, and it's not perfect? Well, I can tell you that it's probably not perfect and it should constantly be improving. It has been improving. Now, is everything going to be failsafe, no problem, 100%? That's probably not realistic. But if the process can get better, let's do it, and let's get everybody that's supposed to be part of it, and understands it, into that space.”

Getting everyone into that space to discuss real solutions honestly and openly, with real change as the ultimate goal, is the only way to go. Nobody in the NFL can afford to stay on their own sides with their own agendas anymore.