Monday Morning MD: Top five medical changes for 2015 season

In this era of player health and safety, medical news continues to make headlines. Every year there are new initiatives implemented. What are the changes for the upcoming season? Below are my top five new things to look out for during the 2015 season.
  1. Medical timeout rule
Some have referred to it as the “Julian Edelman rule”. Controversy began when the Patriots wide receiver was not immediately removed or evaluated when the medical spotter called down to have him checked. From my direct observation covering the Super Bowl, New England appeared to follow all concussion rules; however, I pointed out potential deficiencies as there was no mechanism to stop a game when the spotter calls down. That is no longer the case. This offseason’s biggest medical rule change is that play can now be stopped to remove a player in order to be checked for concussion. Although this is a clear improvement to safety, it also comes with some unintended potential consequences. A key player could be removed for one or more plays for evaluation when he has no head injury. There could be issues with itchy trigger fingers or perhaps the spotter being too conservative in stopping a game. It is also possible that the spotter won’t see the replay before the next snap of the ball. Watch the controversy when a star player who turns out to not have a head injury misses a key 3rd or 4th down play. Since a medical timeout can only be called when a player has “obvious signs”, and a player with any sign of concussion is supposed to be held out, does the call down effectively end his day? Medicine is an art, not an exact science, and to ask a medical spotter to be instantaneously correct may be too much to ask. Although this is a step in the right direction, look for this new rule to cause some controversy this year.
  1. New extra point rule
Moving the line of scrimmage on extra point kicks back to the 15-yard line is supposed to add some excitement and encourage teams to go for two. However, there may be the unintended consequence of increased injury. We all know collisions are more severe on an important fourth down or goal line play. A two-point conversion is essentially both. If there is an increase in going for two, certainly there is more injury risk than a routing extra point kick from the two-yard line. Even if the extra point is kicked from the 15, that still may result in increased injury risk. Maximum rush in attempt to block a field goal has considerable head, neck and knee injury risk. In my time as head team physician, we routinely removed lineman with recent neck issues from the field goal protection unit. An extra point from the two is almost unblockable as kickers can lift the ball quickly. With the risk of a fake, many teams often played “safe” and didn’t rush with vigor. With the kick now coming from the 15, there is little risk of a fake and teams are likely to go all out for the attempted block, thus creating an additional unintended increase in injury risk. I hope this new rule does not cause get any players hurt, but it bears watching. Maybe this is why the league only has this new rule on a one year trial basis.
  1. New contact rules
Three new rules were introduced to increase safety. Chop block, peel back block and extended receiver protection were all expanded. Chop blocks are known to cause ankle and/or knee injury. Chop blocks are not yet completely illegal, but their prohibition was expanded beyond the tackle box. Peel back blocks are potentially dangerous for head and neck injuries as a player pursing a ball carrier doesn’t see the hit coming., All offensive players are now prohibited from using that technique anywhere on the field. Defenseless receiver rules were an early tenant of player safety. Extended receiver protection now protects against a free shot during a turnover. Although all of these new rules help, they will only help prevent a small fraction of concussions and knee/ankle injuries. Look for more rules changes to come in the continued quest to make the game safer.
  1. Visiting Team Medical Liaison
The NFL is creating a new medical position. The VTML is intended to serve as a resource for the visiting team. Remember, doctors are licensed by there home state and don’t have hospital privileges across the country. Last season, Miles Austin (kidney) and Justin Hunter (spleen) were hospitalized on the same day and left behind as their teammates flew home. When this inevitably happens again this year, the VTML would be in charge of their care. In the past, this function has been filled by the home team doctors. We routinely would help the visiting team medical staff. We did this as a courtesy and also because we knew we likely would need assistance on the road ourselves one day. Believe it or not, the medical profession is relatively close knit and when it comes to medical care, we don’t compete against each other like players or coaches do. My medical team provided access to care, medication and even admitted visiting players to the hospital when needed. I even got calls prior to game day. Once a player unexpectedly broke his hand in an altercation with a TV analyst and needed an X-ray the night before a game. Often there were calls for help with the travel party including sick family members. I have aslo acted in this host physician role for both teams in Super Bowl XXXII and XXXVII. For the Super Bowl, neither team doctors are typically local, so this liaison position is definitely needed. This new change will remove the responsibility from the home team docs and provide the visiting team direct access. This is not going to be a big change. It would have been unethical for me to have not helped a player just because he was on the opposing team. Drug Enforcement Agency rules disallow team physicians from bringing controlled substances with them as they travel. Remember the surprise DEA inspections last year? The VTML could also assist teams to procure needed medications when on the road.
  1. Airway Management Physician
A specially designated “emergency” doctor has been on the sidelines for 16 years. In the beginning, the NFL requested a trauma surgeon but we felt the most important emergent function for life support is intubation capability. We choose a certified anesthesiologist as a physician who does hundreds, if not thousands, of breathing tube placements a year. Some teams have chosen emergency room doctors. Trauma surgeons have been largely phased out as no one is “cracking a chest’ on the field. This position was originally called the RSI (rapid sequence intubation) doctor, then the EAP (emergency airway physician) and over the last two years has been called the AMP (airway management physician). Most people just refer to the specialist as the “red hat”, as he is outfitted for easy recognition by the league in a bright red shirt and red baseball hat. The AMP is easily recognized on the home team sideline at the 30-yard line, unless he is on the Chiefs or Cardinals sideline where his colors blend in. Fortunately, no intubations have been needed on any players, but better safe than sorry. The NFL is now introducing new standards for this position and each doctor will have to document his intubation skills and be certified by the league for the role. Future The biggest change may be the creation of new NFL chief health and medical advisor position. This May, cardiologist Betsy Nabel, of Harvard/Brigham and Woman’s hospital, was named to the role. As an outsider to football, she potentially can provide valuable insight with a fresh, unbiased look. This is a big step in the right direction. The question is, with her only dedicating one day a month to the job, will she have time to make substantive improvements to player health and safety? Follow David on Twitter: @profootballdoc Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.
Dr. David Chao
Two decades of NFL team physician experience including two Super Bowls and two Pro Bowls. Providing unique perspective to injuries and the NFL sideline/locker room. Successful orthopedic surgery and sports medicine practice in Southern California.

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