The Concussion Blog

This past week there were some prime examples of concussions, including mechanism of injury and how they are currently handled – some say mishandled – in the National Football League.  Now the debate rages on about when exactly a player should be pulled for evaluation.

In many cases this is absolutely obvious, for example Johnathan Baldwin of the Kansas City Chiefs last night in Pittsburgh.  As he laid out for a catch his head bounced off the ground and he immediately showed a fencing response and was “limp” on the field in a semi-prone position.  He “came to” and tried to get to his feet, key word being “tried”, as he was wobbly and needed help from a teammate and the official to stand.  The official then summoned the athletic trainers to aid in getting him off the field; it was obvious that Baldwin needed to be evaluated for a concussion (side note: the Chiefs are calling his injury a “neck”, which he could have hurt on that play but once again its an attempt to muddy the water, IMO).

To the credit of the NFL medical staffs these types of situations are rarely missed anymore, especially with the observer in the press box helping with the identification of potential head injuries.  I would dare say that these type of situations are missed more often at college, high school and youth level football games than the professional level; which is way more disturbing.

However, the debate remains about those players that don’t show overt signs of concussions but take seemingly obvious hits that could result in concussion.  In Week 10 the “poster boy” for this was Jay Cutler, as he released the ball he was blasted up high and then laid on the field for a second.  He seemed to have his wherewithal when he returned to his feet and finished the first half.  Reports then have it that he reported symptoms at halftime, was evaluated and deemed to have a concussion.

In my experience, at the high school level, if the Cutler example were to occur that player would be on the sidelines with me, no questions asked getting an evaluation for a concussion.  My reasoning would be; mechanism of injury, delayed response to get to feet, grabbing head, and just “not looking right”.  I have done this many times in my career, at the behest of coaches at time, and 90% of them turned out to be exactly what I thought they were, concussions.  I had and continue to have ZERO reservations about the 10% that were not concussions having to miss some plays.

It’s a bit more dicey at the professional level, many factors play into the decision of yanking the player, Mike Florio of ProFootballTalk took a quick look at one of the pressing issues in a post;

It’s easy to wag a finger at the NFL for not requiring teams to do a better job of yanking players who may have suffered concussions from games.  But there’s a potentially significant consequence to erring on the side of safety.

What if the player doesn’t have a concussion?

In that case, a key player (like the starting quarterback) could be unavailable during key stretches of a game, while he’s screened for a concussion that he ultimately is deemed to not have.

At some point we are going to have to forgo the “what if” on the clear side of injury to make sure no players slip through the cracks.  It should be an automatic response of the athletic trainers and medical staffs if they see something like Cutler happen the player needs to be checked out.  Florio mentioned the possible objective measures that might help in determining when a player gets pulled for an evaluation, the problem there is that both the league and NFLPA is resistant to having such technology on the field, for various reasons.

The other less discussed issue in a situation like Cutler’s, but was exposed in the Mike Vick situation is that concussion symptoms can be delayed.  There are times when the headache, confusion, and visual disturbances (not all-inclusive list) will come on after the player has “settled” down and masking mechanisms go away.  In those cases we as athletic trainers are solely relying upon the players to be honest; which can be difficult – a recent survey shows 56% of pro players would hide symptoms to continue to play.

I tweeted on Sunday something to the effect of “the day I see an athletic trainer run on the field and pull a player no questions asked is the day we have made significant strides.”  It happens on high school fields all over this country as fine athletic trainers notice the situation and do what is expected and right.  The complicated professional level is a whole ‘nother animal; with players knowingly gaming the injury and playing for a profession, resistance is high.  Not to mention coaches who would be reluctant to allow an athletic trainer to jump out on the field and pull the starting QB just because he/she “has a feeling”.  There are too many conflicts of interest at this time for the ideal situation to be in place.

When a player shows overt signs there shouldn’t be an issue, when there is a hit that was especially remarkable with “tweener” signs it should be another quick response.  In those cases though instead of a screen, “are you OK, you know where we are?” the player should be taken through the protocol.  In the case of a player like Cutler that was on the ground, probably due to both his head and getting rocked in this violent game, the answer is not as clear.

The good thing was that from reports Cutler was honest and when he had the chance to calm down he had symptoms and reported them, then they did the evaluation and pulled him.  I would be interested to see what the communications were from the observer in the stands about that hit.

It may be a convoluted mess in the professional ranks, but it should not be at the lower levels, if you see a Cutler situation in youth or high school football get that player out for an evaluation, no questions asked.