Finding a true “independent” health care provider for concussions in the NFL is a sticky situation; the NFLPA says they want one and the League is saying no. Of course there are various reasons as to why the League would not want an independent neuro there; cost being one issue, the other issue is that the players may actually be in greater peril – and I agree. Dr. Richard Ellenbogen co-chair of the NFL Head, Neck and Spine Committee explained this in an article in USAToday;
“No one knows the players as well as the athletic trainers, period.
“Having said that, some teams already have neurosurgeons on the sidelines. Having a doc show up just for a game takes away from the all-important baseline exam and continuity of care. It would be like getting operated upon by a surgeon who did not see you pre-operatively. Is that safer than having someone who saw you beforehand? The baseline is all important in making an assessment if a player is OK after a hit.”
Concussion are so subjective, most cases do not involve overt signs and it is incumbent upon the player to report what is going on. Trust is a HUGE factor for players – of all ages – but more so in the NFL where they are making a living by playing football. Although the tests are there and meant to be as objective as possible it is still a clinical diagnosis overall. The only health care professional on an NFL sideline that knows the players best is the athletic trainer. This would be seconded by the team doctor; the other specialists that are on hand (including a team neurosurgeon) have limited intimate knowledge of the players as they see/interact on a weekly basis.
I do have a potential solution however, why don’t team employ a dependent neurologist or neurosurgeon? Granted they have to make a living working with the general public, certainly they can carve out time to provide better – not fully adequate – coverage from a “brain doc”.
Just as the team orthopedic surgeons do the preseason physical and consult on weekly injuries, then are on the sideline for evaluation of bone injuries; the team neuro could provide the same. The preseason baseline tests (NFL adapted SCAT2 and computer based tests) could be done by the team neuro, a weekly visit (or more) to familiarize themselves with players and discuss current issues with the athletic trainer and finally being on had during the game to make the all important decision.
I still believe that the athletic trainer would be the most qualified to make the decision but the ultimate “go/no-go” is often and usually exclusively made by a doctor, in this case you would have this. Granted any doc worth their salt would rely heavily on the input from the athletic trainer.
This proposal then would provide another benefit; when being cleared by the League via the independent neuro there would be peer-to-peer discussions in all cases. Plus, the team neuro would have a better picture of the player to present to the League.
I have many opinions as to why the current system may not be working as well as some hoped, the biggest issue being conflict of interest (as you will see in a later post) but this proposed system would add another specialist layer for the players. As an athletic trainer if I had a great working relationship with a neuro doc I would be much more inclined to defer (although in the current health care hierarchy we always have to) to their judgement if they had a clinical background of the patient.
Side note: Dr. Ellenbogen also wrote about why players were not pulled from the game (underling my post from Tuesday) when the world thought they sustained a concussion during the games last week;
“The physics of the hit do not always translate into a concussion,” Ellenbogen wrote. “The amount of impact does not always correlate to the concussion. It is often related to angular acceleration, not linear acceleration of the hit. Need to look at player and have baseline exam and compare to that.
“Smith was concussed on second, not first hit. Cutler was OK after first hit but got new symptoms as the game progressed. And remember the problem is that with all the adrenaline, the concussion was not immediately obvious to the players. Both became symptomatic as they played further. That certainly is not uncommon for concussions to evolve. If you have seen one, you have seen one. They are all different.”