March 25, 2015 - Dr. David Chao
New medical timeout rule still might not prevent a Julian Edelman situation
The new NFL rule that allows the “eye in the sky” to stop play is certainly a positive move; however, it won’t immediately remove all concussed players and might even create a different set of new problems. I applaud the owners for taking a step in the right direction but this change won’t perfect the league concussion protocol. Concussions are like snowflakes; no two are the same. A big hit can lead to no head injury, and a minor blow can result in lost time. It is admirable and necessary to try to legislate head injury evaluation and treatment. Unfortunately, that is a tall order. Inspired by Edelman staying in the Super Bowl after a big hit, it is ironic that this new rule might not even have caused a stoppage of play in that situation. In order for the ATC (athletic trainer, certified) spotter to call a medical timeout, he/she must determine a player exhibits “obvious signs of disorientation or is clearly unstable”. The spotter’s threshold to simply call down is much lower. They are free to report any suspicious hit and have that player checked. My assumption is this process will continue. The new rule creates a new category to notify the side judge for a medical timeout if obvious head trauma exists. The “eye in the sky” is now asked to judge severity of what is seen much like a referee adjudicating "running into" versus "roughing" the kicker. Would Edelman have fallen under the obvious category? My take is some spotters would have called it obvious and signaled a medical timeout why others may have considered it suspicious and demanded an evaluation but let play continue. Currently there is no standard for calling down to the sidelines and strict rules would be hard to interpret anyways in the subjective world of concussion detection. My first hand experience was that some athletic trainers notified us frequently with any remotely suspicious hit and others rarely called down. The NFL should institute some formal guidelines and training so there can be some consistency between spotters now that they have more power. Bear in mind a medical timeout may not always be indicated before the next snap. Video signs of concussion may not be readily visible in real time or may not be seen until replay from a different angle. This might create an awkward situation for independent ATC making what appears to be a delayed call. In addition, expect a player initially removed by medical timeout who is appropriately cleared to return to be later removed again. Often concussion symptoms are delayed in onset and thus this situation is inevitable. The only way to prevent this scenario is to declare anyone subject to a medical timeout be pulled for the remainder of the game. The new rule only requires a one-play sit out. There is no mandate for locker room evaluation or permanent removal from the game. If the indication for calling a medical timeout is “obvious” signs, then shouldn’t that lead to a locker room evaluation resulting in a minimum 10-15 minute absence from play? With NFL protocol stating a player with any sign of concussion is not allowed to return, does a medical timeout being called imply that player can’t return? The name of the new rule also may be misleading. It is less of a medical timeout than a medical stoppage of play. Play resumes as soon as the player in question leaves the field. There is no additional time allowed to see if a player can be cleared to return. The reality is if a medical timeout is called, the player will inevitably miss more than one play. It would take a minimum of several minutes for the team medical staff to perform a sideline screen and view the injury video before a player could return. This might affect the outcome of games by missing key third down play or a pivotal series when there is no concussion. Obviously if a player has a full evaluation, that would take even longer (10-15 minutes). If the spotter sees enough to call a medical timeout, doesn’t that imply that the player should go into the locker room for full evaluation? The new rule was inspired by the fact Edelman played six more plays during a key Super Bowl drive after the spotter called down to have him evaluated. We don’t know that Edelman even had a head injury but the perception of ignoring concussions on the NFL’s biggest stage was enough to lead to the unanimous vote from the owners. Possible he didn’t have a concussion. Possible by staying in the game and by avoiding immediate exam, he had time to clear by the time he was evaluated. Possible he still had symptoms but hid them to stay in the game when evaluated on the sidelines. Let me reiterate that Edelman was checked during the Super Bowl and the concussion protocol at the time was followed. Some media were critical of the Patriots medical staff, but I don’t believe they did anything wrong. I don’t think it is likely that anyone would put their own medical career in jeopardy by purposefully ignoring concussion symptoms to win a game and they had no power to stop the game. Clearly it is not believable that the sideline unaffiliated neurological consultant, who is a respected independent physician practicing medicine in the Phoenix area, was paid off or somehow was a Patriots fan caught up in the moment. As an orthopedic surgeon, admittedly I was never primarily responsible for examining concussions in the NFL. We always had a primary care physician experienced in head injuries doing our evaluations. However, as head team physician, I oversaw the process and participated in all mandatory conferences, policy discussions, emails and conference calls. I always felt the concussion evaluation game was a no-win situation as there will always be second-guessing. Now some of that scrutiny will fall onto the ATC spotter. Although I like the new medical timeout rule, I predict it will end up causing controversy next season. Someone will get quickly put back in game and criticism will come. Someone without concussion symptoms will miss an important play or series simply because of a trigger-happy spotter and the losing team will cry foul. The bottom line is the concussion issue is much more complicated than the public makes it out to be. The medical timeout is a good addition; it just may not be the answer everyone hoping for. 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.