What you see above is Texans quarterback Tom Savage experiencing what’s known as the fencing response after getting his head slammed into the ground, as obvious a sign of a brain injury as there can be. His Sunday should have ended right then and there, and yet just a few minutes later, Savage returned to the game. Finally, after running three more plays, he was mercifully removed from the field for good.
This disturbing sequence of events once again brought attention to the NFL’s concussion protocol, which is once again being widely criticized as inadequate. It’s true that the protocol cannot definitively account for every concussion-related scenario during a practice or game, but the real scrutiny ought to be brought to bear on the NFL’s continued reluctance to enforce what’s actually in the protocol, rather than the protocol itself.
The protocol is a set of guidelines the league and the NFLPA put into place in 2013 to codify what should be done when a player sustains what appears to be a brain injury. It has its limits, but by mandating the presence of certified athletic trainers (ATCs) up in the booth to look for instances of possible head trauma, in addition to placing neurotrauma consultants (UNCs) with no team affiliation on the sidelines to assist in the diagnosis of possible concussion symptoms, the protocol was a significant step toward safeguarding players’ health. In addition to the in-game protocol, there is also a separate set of specific procedures that governs how to handle players after a concussion diagnosis has been confirmed. All told, it’s a marked improvement from the way things used to be.
After a public outcry following a 2015 hit taken by Case Keenum, the league and the NFLPA last year rolled out an enhanced protocol that added compliance guidelines and specific punishments for any violations—in effect, policy measures designed to ensure the protocol would be enforced. Violators now risk disciplinary actions ranging from fines to the forfeiture of draft picks, with a neutral arbitrator to settle any disputes. But, as befits the NFL’s approach to disciplining anyone other than the players, the enhancements have proven to be all bark and no bite. The arbitrator is empowered only to issue a report to commissioner Roger Goodell, who retains (in the league’s own words) “absolute discretion” to determine any penalties. And since these enhancements were put into place just before the start of the 2016 season, not one punishment has been meted out.
In fact, it took all of one game for the toothlessness of the supposedly improved concussion policy to become obvious. In last year’s season opener, Panthers quarterback Cam Newton—at the time, the league’s reigning MVP—endured a series of brain-rattling hits, yet was never checked for a concussion until after the game. A cursory reading of the protocol that was in place at the time made it plain that the guidelines weren’t followed. The league and the NFLPA launched an investigation; one month later, the two sides explained away the whole thing by saying Newton didn’t have to be checked out despite what everyone watching the game had seen:
After reviewing the replay and observing Mr. Newton from the sideline, the Panthers’ medical staff and the [unaffiliated neurotrauma consultant] agreed that no further evaluation of Mr. Newton was necessary as they did not observe signs or symptoms of concussion.
This didn’t stand up to even slight scrutiny. According to the language of the protocol that was in place at the time, any one of those multiple, easy-to-see shots to Newton’s head should have triggered a mandatory concussion evaluation. See here (emphasis mine):
In the event the occurrence of a concussion is unclear, or a player sustains a mechanism of injury (“big hit”) that is reasonably expected to give rise to a concussion, and/or a concern is raised by another player, coach, game official, ATC spotter, or Unaffiliated Neurotrauma Consultant, the player shall be removed immediately from the field by Club medical personal. The Team Physician best qualified to evaluate concussion shall assess the player by, at a minimum, performing a focused neurological examination …
This never happened. Somehow, both the Panthers’ team doctors and the UNC assigned by the protocol to serve as a bulwark against team interference were able to determine that Newton needed no additional evaluation ... from the sideline. Here’s just one of those hits:
Let’s grant that it was possible this was a series of human errors and not a deliberate decision to keep Newton on the field for competitive reasons. It was still a violation of the protocol as written, rather than a failure of the protocol itself.
This offseason, the league quietly amended the protocol. The reference to a “big hit” that “is reasonably expected to give to give rise to a concussion” was changed, though the meaning is still largely the same. The protocol now says:
When the Booth ATC Spotter observes a player who is clearly unstable, or displays any other Potential Concussion Signs (defined in Section I.C. above) following a mechanism of injury (e.g., a hit to the head or neck), he/she will contact the team physician and UNC by radio to ensure that a concussion evaluation is undertaken on the sideline.
Concern over a possible concussion can be raised by “the club’s athletic trainer, team physicians, Booth ATC Spotter, coach, teammate, game official or Unaffiliated Neurotrauma Consultant.” Warning signs of a potential concussion are defined as follows:
- Slow to get up following a hit to the head (“hit to the head” may include secondary contact with the playing surface);
- Motor coordination/balance problems (stumbles, trips/falls, slow/labored movement);
- Blank or vacant look;
- Disorientation (e.g., unsure of where he is on the field or location of bench);
- Amnesia, both anterograde and retrograde;
- Clutching of head after contact; or
- Visible facial injury in combination with any of the above.
This year’s updates to the protocol also call for the presence of blue tents on the sidelines, under which players are to receive an initial concussion assessment. That assessment, the protocol says, “at a minimum, must consist of the following” (emphasis mine):
i. A review of the “No-Go” criteria reviewed above (Loss of Consciousness, Confusion, and Amnesia), which, if present, requires the player to be brought to the locker room immediately and he shall not return to play;
ii. Inquiry regarding the history of the event;
iii. Review of concussion signs and symptoms (See, Section I (C and D));
iv. Maddock’s questions;
v. Video Review of the injury (detailed below); and
vi. Focused Neurological Exam, inclusive of the following: (A)Cervical Spine Examination (including range of motion and pain); (B) Evaluation of speech; (C) Observations of gait; and (D)Eye Movements and Pupillary Exam
Note that a video review is required. In Savage’s case, that video would have shown that he demonstrated the fencing response, which indicated that Savage had experienced brain trauma. Did the spotter or the UNC view the video? If not, why not? A story published Thursday in USA Today attempted to provided some clues:
The booth spotter (each team has one assigned) doesn’t have access to all the television replays that fans do at home, but they should. Time is also an issue, though. The spotter initially is watching action down on the field, but then turns to the screen and quickly has to cut clips of injury plays and send them down to the sideline to the team’s medical staff.
But league spokesman Brian McCarthy told me via email this wasn’t true:
Two certified athletic trainers (spotters) and two Injury Video Replay System (IVRS) booth techs are assigned to every game. One spotter and one tech are assigned to each team. They have access to broadcast video coming straight from the network feed.
There is an IVRS cart on each sideline that shares the feed with that in the booth. Injury video field techs support medical personnel when reviewing injury video. The techs in the booth can play back footage for the sideline medical staff as needed.
So, at least according to the NFL, techs for both teams are supposed to be in the booth and on the sidelines, and their job is to review the video, which includes the broadcast feed. It’s true that 49ers defensive end Reuben Foster was also injured on the same play as Savage, but Fox showed the replay of the hit Savage took—and his troubling reaction to it—several times. Again, even if we allow that there might have been some chaos and confusion at work because Foster’s injury had to be tended to on the field, the protocol spells out in no uncertain terms that a video review of the hit Savage endured was a mandatory part of the action plan. Whether anyone actually reviewed that video will be determined by the investigation to which the league and the NFLPA have committed.
Here’s where it gets tricky. Savage was evaluated for a concussion once he got to the sideline—this, too, was caught on camera—but Savage passed that evaluation, according to Texans head coach Bill O’Brien. The protocol does allow for a player to return to the game if he passes that initial test, and such a thing is possible, even after a big hit to the head. (Symptoms sometimes may not manifest themselves for minutes, hours, or even an entire day, if at all.) The protocol also calls for additional periodic tests after that initial evaluation, and on Monday, according to a transcript provided to Deadspin by the Texans, O’Brien told reporters that he requested that Savage get checked again after the Texans’ defense was on the field for a brief three-and-out after the series in which Savage returned to the game. It was only then that Savage showed symptoms and was pulled for good.
Savage’s situation isn’t even the first of its kind from this season. Last month, Colts quarterback Jacoby Brissett took this shot to the back of the head:
Brissett didn’t miss a snap the rest of the game even though he, too, was evaluated on the sideline. The reason? He passed the test. But sometime after the game, Brissett began to show symptoms and was placed in the protocol before he could play again; he was cleared to start the following week. Again, though, watch the GIF. Watch the way Brissett reached to grab the back of his head after taking that shot from Steelers defensive end Stephon Tuitt. Even if he didn’t show immediate symptoms, the video was supposed to factor into the evaluation he was given, according to the protocol. Yet, by all appearances, that didn’t happen.
Here’s another example from last month where the video is damning. This is Seahawks quarterback Russell Wilson taking a shot to the chin from the Cardinals linebacker Karlos Dansby, who was flagged for unnecessary roughness:
After the play, Wilson was clearly hurting:
Referee Walt Anderson recognized this and sent Wilson to the sideline for a concussion test. Wilson wanted no part of it, though, and insisted he was fine. NBC’s cameras captured Wilson entering the evaluation tent and refusing to be evaluated:
Wilson missed just one play. But before the Seahawks’ next possession, Anderson was caught on camera telling Wilson he had to get checked, which Wilson did:
Here again is the protocol functioning exactly as it should: A game official did the right thing, recognizing that Wilson’s brain had endured the kind of blow that warranted an evaluation. That players sometimes need to be protected from themselves is one major reason the protocol exists. But here again is where things get tricky: Wilson not only passed the test and played the rest of the game, but was never subsequently diagnosed with a concussion. He hasn’t missed a snap since. As with Savage, the league and the union are looking into the fact that Wilson was never evaluated. But there’s no denying that no one on the Seahawks’ sideline stopped him to make sure he was tested before he took the field again, as the protocol requires. That’s a cut-and-dried violation.
Back to Savage’s hit. As grim as his fencing response was, another replay showed that he got right back up and ran off the field immediately afterward, even as an official was right there to observe the whole thing:
The fencing response is what distinguishes Savage’s brain injury from what happened to Brissett and Wilson, but Brissett grabbed at the back of his head, and Wilson looked like he needed to rearrange his jaw. Savage and Brissett eventually developed concussion symptoms, but Wilson didn’t. The only common thread here is that there’s no foolproof way to prevent brain injuries from happening in football, short of completely changing football itself.
In his email, McCarthy told me that “medical staffs have completed hundreds of applications of the protocol,” and this is indeed true. McCarthy then reiterated that the league and the NFLPA would be investigating the Savage scenario before adding, “Should that review determine that the protocol was applied improperly here, the club will be disciplined.” If that were to happen, it would be a first.