A Simple Suggested Paradigm for Football Game Concussion Management: The Fight Doc in a Lifeguard Chair With Unobstructed View and Authority
Atul Gawande’s Checklist Manifesto illustrates the potent power of a simple common-sense change: insisting that physicians and other health care providers always use simple checklists, to insure that all necessary tasks are completed, almost always causes the number of medical errors to plunge.
I wrote two weeks ago that the Shane Morris events showed that Michigan (and other schools) needed to place a medical staffer up in the press box, armed with several TV monitors, to watch the field below for any on-field event which might raise some suspicion that some head or concussion injury may have occurred. The press release later issued by Michigan pronounced that Michigan would commit to having just such a press box medical monitor at every home game.
I am proposing another simple step to allow better assessment of potential football concussion injuries. I was led to this thinking because I found this interview of Michigan sideline neurologist Dr. Jeff Kutcher, reported last Thursday in the Detroit News, so disquieting.
What stuck in my craw was Kutcher’s admission that his position as the Michigan football team’s “sideline neurologist” gives him the “worst seat in the house.” The implications of this startling admission suggest that Kutcher partially misunderstands his function there on the sidelines, and also probably fails to perceive the rapidly evolving, and ever-increasing tension between two conflicting forces there on those same sidelines.
Concussions, Kutcher and others will tell you, are what clinicians call “occult” injuries, which means that the physician or trainer has difficulty making a diagnosis as a result of garden-variety physical, neurologic or opthamologic exams. The injury remains, in many respects, “unrevealed.” Forty years ago, concussions and other brain injuries were almost completely unrevealed, because the medical and diagnostic tools were so primitive; as a result, coaches, players and even doctors could more easily believe that no injury occurred after impact to the head — “out of sight, out of mind.” And forty years ago, the “smashmouth” football ethic predominated, with an emphasis on “playing through it,” and “shaking off” the after-effects of “getting your bell rung.” Play when you’re hurt, and you’re a hero. All those old cliches grow out of the old Dick Butkus, Bobby Layne, never-say-die concept of “toughness.”
But the science has rapidly improved, and new empirical data, including sophisticated new imaging techniques, have confirmed the presence of changes to the brain as the result of impacts on the field. The risk of injury is now much more obvious, though much remains undefined.
But the game is still managed by men who apply that that old Dick Butkus ethic. Michigan’s head coach Brady Hoke, for example — an extraordinarily decent man — still endorses smashmouth, never-come-out-of-the-game football. As a result, he made a fool of himself at the Minnesota game post-game presser when he blithely insisted that — contrary to all the current science — if Morris had felt he needed to come out of the game, he would’ve taken himself out. Michigan’s chaotic response to that Morris concussion, in fact, suggested an athletic department still governed by the old laissez-faire approach to concussion management.
But calling that old-school concussion-management approach “laissez-faire” overlooks a more profound factor causing it to linger on the sidelines: almost every coach believes that that “toughness,” and “smashmouth” and “play through the pain” is what wins games. And AD’s believe in it because winning generates gross income.
Smashmouth Clashes With New Science: The big battle on every football field now is between the new medical science (and resulting new prudent medical risk management) against the old, outdated smashmouth never-come-out ethic. And Dr. Kutcher, there on the sidelines, operates at the very juncture where those two forces meet.
But by passively accepting that his seat is “the worst in the house,” Kutcher backs away from that important juncture where smashmouth meets new science. He’s literally and figuratively buried in the pack, and overwhelmed by it. And his passivity in accepting “the worst seat in the house” (ie, with no line of sight to the game) reflects that he might not thoroughly understand that his important role is to perform a “check and balance” function not unlike the role of the three branches of the federal government. Kutcher must be an opposing force, insisting that the science and medicine prevail over the relentless drive to win (and make money) which often overwhelms college sports.
Based upon his passive acceptance of his “no-line-of-sight” position on the sidelines (and his apparent failure to previously adopt the Northwestern concussion management model, which several years ago added a medical monitor in the press box), it would appear that Kutcher might liken himself to the paramedic who stands at the finish line at the high school cross-country meet, available to administer smelling salts or perhaps oxygen to the several overcome runners who typically collapse, without significant subsequent health risk.
Sideline Medical Man as Fight Doc: Kutcher, instead, needs to perform his “check and balance” function, in opposition to the strong forces in favor of winning and making money, by performing more like the “Fight Doc” at a prizefight, who is authorized to stop the fight, and remove the athlete from the performing stage, no matter what any coach or fan believes ought to happen. But in order to do that, he needs to watch every play. For example, had Kutcher actually seen the Morris hit, he should have had the authority to directly intercede, and require that Morris immediately come out of the game — without consulting with anyone.
Definition of Duty Needs Focus on Possibility of Concussion: Some of Kutcher’s confusion may derive from the policies adopted by the NCAA, which suggest that removal from competition is required for those players “who are experiencing signs, symptoms or behaviors consistent with a sport-related concussion.” The language is too vague; the intent unclear. It should more directly state that the obligation to remove the player arises when he shows signs of a “possible concussion.” The semantic difference is important, since my suggested language emphasizes the need for immediate evaluation of both injury and possibility of injury. And, as regards Kutcher’s check and balance function, Kutcher should have explicit final authority to operate as the Supreme Court, with the complete and final power to intercede and unilaterally remove a player from competition.
The Fight Doc in the Lifeguard Chair: All of which leads to my proposal: the sideline neurologist needs to sit in a Lifeguard chair — the same kind of wooden structure which put beach lifeguards up high, for the best possible line of sight. The sideline medical professional, whether trainer or neurologist, needs to sit up there with unobstructed view. (Unless he is occupied with performing a neurologic exam.) The chair is hardly expensive (Michigan can borrow one from its tennis team, which has umpires perched in the same kind of elevated seat.) Yes, the elevated “high chair” might block some views behind the neurologist, but where player safety is involved, that is a clearly secondary concern.
Fight Doc With the Best Seat in the House: Some might contend that the “aerial-view” second monitor located in the press box eliminates the need for Kutcher to sit in that chair. I don’t agree: the examining medical man does a better exam if he sees the original mode of injury. But, even assuming no new Lifeguard chair is required, because a press-box monitor exists, the proposal has nonetheless has great utility across every high school and small college football field, because it is a cheap, effective — and highly symbolic measure to improve concussion (and other injury) monitoring. If there is only one medical staffer or trainer on the field, that person should have the best seat in the house, where he can see the mode of injury, and intercede with authority to evaluate any “possible” concussion.
Michigan just hired a new highly respected physician, Mark Schlissel, as its president. He is ideally situated to grab and address what has become a significant public health issue: what is the state of the art concussion management protocol at any level – high school, college and pro. The Ray Rice video thrust Roger Goodell and Ray Rice to the forefront of our culture’s evolving struggle with domestic violence. The Shane Morris video thrust Michigan to the forefront of the conflict between the new science and the old smashmouth ethic. Dr. Schlissel, as president of one the world’s great universities, has a bully pulpit on a Lifeguard seat of his own, with the explicit authority to intervene to change things. Football needs a Fight Doc in a Lifeguard Chair, with the best in the house, with unobstructed view and authority.