Concussions, by the New Book – N.F.L. Teams Now Operate Under a Concussion Management Protocol

It happens dozens of times in every N.F.L. game. There is a fierce collision, or perhaps a running back is slammed to the ground. Most of the time, all the players rise to their feet uneventfully.

Other times, as the pileup unravels, a player gets up slowly. His gait may be unsteady.

For decades in the N.F.L., the operative term for the situation was that someone “got dinged.” It was a cute, almost harmless-sounding description of what was often a concussion or a worrying subconcussive blow to the head.

But with the N.F.L. agreeing to pay hundreds of millions of dollars to settle a lawsuit brought by about 5,000 former players who said the league hid from them the dangers of repeated hits to the head, a backpedaling league has corrected its lingo and hastily amended its methodology. The N.F.L. now has a concussion management protocol, outlined in an inches-thick document that commands teams to institute a specific, detailed game-day and postconcussion course of action.

Once, the treatment of players with head injuries varied from team to team and could be haphazard. Beginning last season, all players suspected of having a head injury — should they lose consciousness from a collision or experience symptoms like a headache, dizziness or disorientation — were required to go through the concussion protocol system. It features a broad cast: a head-injury spotter in the press box, athletic trainers on the bench, doctors and neuro-trauma specialists on the sideline and experts in neuro-cognitive testing in the locker room.

The system is far from foolproof — players with serious symptoms remain in games. But as the N.F.L. grapples with a sobering threat to the welfare of its work force, not to mention a public-relations nightmare, the new concussion protocol is meant to establish a systemic, itemized policy on how potential brain injuries should be handled.

Based on multiple interviews in the last three months with athletic trainers, players, doctors and head-injury specialists associated with the Giants, the following is a window into how the concussion protocol is designed to work on one team.

Keeping an Eye Out

“Before the season begins, I make it a point to tell the players that we’re never going to use the word ‘dinged’ again,” said Ronnie Barnes, the Giants’ senior vice president for medical services, who has been with the team since 1980. “It’s a traumatic brain injury. I say to the players, ‘Each time you get a concussion, you’ve injured your brain.’ ”

Perhaps the most novel part of the new protocol is the advent of a head-injury spotter in an upper-level booth at every stadium. The spotter is a seasoned athletic trainer who is selected, trained and paid by the N.F.L. Also in the spotter’s booth are a video monitor and a video operator who can instantly replay a game sequence to scrutinize the mechanism of a potential head injury.

The spotter watches both teams and can communicate directly with the athletic trainers and doctors on the field via telephones that ring on the benches and walkie-talkies that are wired to earpieces.

Jim Gossett, the spotter for Giants games at MetLife Stadium and an athletic trainer at Columbia for more than 30 years, said he looked for players who appear out of sync.

“It might be a player whose balance seems a little off, or he might be shaking his head after a hit,” Gossett said. “Sometimes it’s just someone adjusting his helmet over and over.

“That’s when I call down and say to the people on the sideline: ‘You might want to check so-and-so.’ Or ‘No. 26 doesn’t look right.’ ”

While the spotter is primarily looking for big hits that may lead to head or neck injuries, he also helps if a player sustains another kind of injury. As often as 15 to 20 times a game, the spotter tags videotapes of plays in which an injury has occurred or one is suspected. The videos are sent to the sideline, where they are viewed on a computer monitor behind the team’s bench.

If alerted by the spotter, the team’s athletic trainers usually approach the players first. Barnes said that in a game on Nov. 23, he approached the team’s wide receivers coach to get a player removed from the field so he could be examined. (Confidentially laws prohibit Barnes from identifying a player unless the player consents to discuss his injury.)

The spotter is not the only person watching for something that looks irregular on the field. In a typical game, about 10 Giants doctors and athletic trainers are on the sideline.

Frequently, the symptoms are obvious, as when a player does not get up off the ground for a few seconds.

In 2011, Giants long snapper Zak DeOssie was kneed in the head making a tackle on a punt, and he was prone and motionless on the turf for about six seconds before rising to his feet.

When DeOssie reached the sideline, Barnes approached and said, “You’re out of the game.”

Answered DeOssie: “On whose authority?”

“Mine,” Barnes responded.

DeOssie began yelling and arguing.

“I felt fine, like nothing had happened,” DeOssie said this month. “I was absolutely convinced I hadn’t been knocked out.”

DeOssie did not return to play, and the next day he saw the tape of the play in question.

“I went to Ronnie Barnes and thanked him,” DeOssie said. “Sometimes, as a player, you have to be protected from yourself.”

DeOssie’s case involved a quick and, in Barnes’s view, obvious medical decision. Not everything is as cut and dried. No two concussions are alike.

Go or No Go

Under the new concussion protocol, a player suspected of having a head injury is interviewed and put through a battery of tests on the bench by a team doctor. Joining the examination is a neurologist or neurosurgeon hired by the league and not directly affiliated with the team. There are two of these league doctors, known as independent neuro-consultants, assigned to every game — one on each sideline.

The initial questioning of the player is fairly standard:

What quarter is it? Who scored last? Do you have a headache? Dizziness? Nausea?

The doctors also put the player through exercises meant to test his balance and cognitive skills. Sometimes, the doctors simply have the player wait on the bench so he can be observed.

“The athletic trainers, who are around these guys six or eight hours a day, can usually spot if someone is not acting normally,” said Dr. James Kinderknecht, the Giants’ sideline physician who most often conducts the initial evaluation.

Dr. Philip Stieg, the neurosurgeon-in-chief at New York-Presbyterian Hospital, often works Giants games at MetLife Stadium as one of the N.F.L. neuro-consultants. He said that the sideline exam was not substantively different from one he would give patients in his office.

“The major difference is that 80,000 people are in the background,” Stieg said.

As the game progresses, a decision has to be made whether the player should re-enter the game or be taken to the quiet of the locker room, where he would receive a more thorough neuro-cognitive examination. The decision is known as the “Go or No Go” verdict.

“Because if someone is taken back to the locker room, he’s probably not going to go back into the game,” Stieg said.

Each doctor interviewed for this article said a consensus in the “Go or No Go” moment is usually reached easily and without disagreements. No one recalled discord.

“Ninety percent of the time, it’s pretty obvious,” Kinderknecht said. “It’s not a whole lot different than talking to somebody who is intoxicated. You can tell.”

But if it involved an elite player, the decision could make or break a team’s chances in the game. The final call, if there is a difference of opinion, falls to the team doctor, who is very likely an orthopedist or sports medicine specialist and not a neurologist.

The doctors who work Giants game said that no team physician had overruled the recommendation of a league-assigned independent neuro-consultant in the two seasons since the concussion protocol was put in place.

Nothing Is Foolproof

But the system established by the N.F.L may not, in every case, ensure the complete independence of the league-appointed neuro-consultant. Each of the principal Giants doctors, for example, is affiliated with the Weill Cornell Medical College in New York, as are four of the five neuro-consultants who work Giants games. In that sense, the doctors are linked colleagues who may share bosses.

Asked if the arrangement compromises the independent dynamic the process is trying to achieve, Stieg said: “I’ve never experienced any kind of pressure to get some player into a game. The N.F.L. told us, ‘We want you to be another set of eyes protecting the player.’

“I’m not paid enough, nor is there enough in this, that I would do something harmful to a patient that also negatively impacts my reputation, which I’ve built 30 years to acquire.”

Dr. Nitin Sethi, a Columbia NewYork-Presbyterian Hospital neurologist who is another of the league-appointed doctors working Giants games, said he had not seen any threat to the integrity of the process.

“We may be from some related institutions, but I haven’t seen any sort of obstruction,” he said. “They’ve given me a free hand.”

The league-appointed Giants doctors work only home games; doctors based in other cities and affiliated with a variety of hospitals work the away games.

For all the measures taken by the team and the league to sift out concussed players, those with concussions sometimes remain in games. They either purposely or unwittingly do not report their symptoms, and they successfully or involuntarily mask any physical reaction to the injury.

Giants linebacker Jacquian Williams played the entire game in Seattle on Nov. 9, and a day later he reported having a headache. Tests confirmed a concussion, and Williams has not played since. He will be benched again this weekend.

“It is disturbing when they show up after a game with concussion symptoms,” said Barnes, who was referring to cases he has seen over the years, not Williams’s situation. “They’ll say, ‘I took a hit and I didn’t think it was that bad, so I stayed in.’

“Since high school, some of these guys have had episodes where they’ve taken a hit and felt something but got through it. We have to change that way of thinking.”

It is becoming more commonplace for players to self-report a head injury. The same day Williams played the entire game in Seattle, Giants running back Peyton Hillis approached a member of the medical staff to say that he wanted to be checked for a concussion. He was taken out of the game and a few days later was placed on injured reserve, ending his season.

Players are also policing one another, tipping off the trainers that a teammate acted oddly in the huddle. Gossett said he had seen game officials alerting medical personnel as well.

If a player is removed from the bench area because he is suspected of having a concussion, inside the locker room, a team doctor, an athletic trainer and the league-appointed neuro-consultant will give him a more thorough assessment.

Taking It Seriously

Since all the players take a series of neuro-cognitive tests, known as baseline testing, in the summer, the team can, in some cases, have the player take a version of those tests in the locker room and compare the scores.

One tool is a software application designed for N.F.L. teams known as the X2 and used on portable touch-screen devices. The player is asked about his symptoms and taken through standardized neuro-cognitive questions — remembering and repeating up to six digits forward and back — and physical assessments not unlike tests that police officers give to drivers suspected of drunken driving.

A player suspected of having a concussion, or clinically determined to have one, is not allowed to conduct news media interviews afterward and is instructed to avoid physical and mental activity. The player sees one of the league-appointed neurologists, usually two days after the game.

When the player becomes symptom-free, he is required to follow a step-by-step recovery that begins with light physical exertion and gradually increases in intensity (as long as the activity does not cause concussion symptoms to return). The Giants do not clear the player for a full practice or a game until he visits with a neurologist a second time. Many players are back within a week. Some can miss months.

“I tell every player I see about the short-term ramifications and things like chronic traumatic encephalopathy,” the neurologist Sethi said, referring to the progressive degenerative disease that has been found in the brains of multiple dead football players and athletes with a history of repetitive brain trauma.

Sethi continued: “They listen. I’ve found that a lot of them know about C.T.E. and are worried about it.”

In the 1980s, when Barnes suspected that a player had a concussion, he would lock the player’s helmet in a trunk to keep him from re-entering the game. Some other players rested on the bench for a quarter or a half and, if cleared by doctors, they would resume playing.

“We don’t do that anymore, which is good,” Barnes said.

Now in his 35th season in the N.F.L., Barnes sees that as progress, but two years into the league’s elaborate concussion management protocol, he admits that the process needs to evolve.

“We really need more education for the players so they know to report their symptoms and not consider playing with them,” Barnes said. “Players are more aware, but I want all of them to come to us and say: ‘I have a headache. I saw stars on that hit.’

“I want the players to take it more seriously. That’s why I refer to it as a traumatic brain injury. I want to be sure they hear that.”

Via The New York Times.