Last month Michigan revised its written concussion protocols, in response to the September 2015 Shane Morris controversy. Those documents correctly exalt the state-of-the-art principle that medical, not athletic, personnel should be the final decision-makers regarding sideline concussion management issues. This principle has already changed sideline behaviors: a decade ago, coaches and trainers, both employees of the athletic department, had authority to make all decisions. New policies switch that authority to medical personnel who are not employed by the athletic department — and Michigan’s policy makes much of this ostensible need for medical independence. This major change in sideline protocol is based upon a recognition that college football’s Mad Bulls of Triumph and Profit have often compelled a coach or trainer to allow the drive to win and make money to override player safety concerns.
But Michigan’s new policy fails — without explanation — to apply this state-of-the-art ‘medical independence’ principle in one very important respect.
There are two major two categories of concussion-management decisions required on the sidelines: 1) Removal-from-Play; and 2) Return-to-Play. Michigan’s policy makes clear that the sideline doctors have the final Return-to-Play authority: after review or testing of the player on the sidelines, it is the physician’s decision as to whether the player will be held out. Disagreement between doctor and coach? — doc wins.
But the Removal-From-Play policy abandons ‘medical independence’: the ‘Spotter’ placed up high (for the first time, after the Shane Morris incident), will have access to replay video-cameras, and radio communication with sideline personnel, but he is not a physician, and he is not employed by an independent medical entity. He is an employee of the athletic department (with certification as an athletic trainer), and is also an Assistant Athletic Director. This is anything but medical independence from the athletic department.
This decision to man the ‘Spotter’ position from within the Athletic Department is all the more troubling because the Removal-From-Play decision ( and the entire concussion management process) are so consistently subverted by one relentless factor: the propensity of players to ‘play through’ and ignore, or even hide, any concussion symptoms. Ali Krieger, for example, a member of the U.S. Women’s National soccer team who has experienced recent severe concussion problems, admits that the player will “always want to play and then make it worse.” And Michigan’s September 2014 mis-handling of Shane Morris after a high hit while he was in the pocket was an excellent example of this unhealthy propensity on the part of the player to ‘just keep going’: after Morris was hit hard in the neck and lower jaw, he got up, wobbled around for a full twenty seconds — while one teammate actually signaled to the sidelines that some replacement for Morris was needed — when Morris’ legs started to go out from under him, causing him to grab for a teammate lineman for support. Yet he was allowed to remain in the game, and ran another play before being taken out! (He was later re-instated to the game.)
And Removal-From-Play decisions are all the more important because the shell-shocked player who wants to remain in the game can often, after that first hit which wobbles him, ‘shake it off’, keep his mouth shut, stay in the game — and no one will ever know.
Morris’ Removal-From-Play was the Glaring Problem, not Return-to-Play: But there has been no evidence that the later re-insertion of Morris into the game was the result of any violation of state-of-the-art Return-to-Play standards. (Yes, the later diagnosis of concussion, on Sunday or Monday, suggests that Morris had symptoms on the sidelines, but no information has been released to support that conclusion.) So the glaring defect in Michigan’s Concussion protocols was the failure of its Removal-From-Play policies. — yet Michigan’s concussion task force has produced a Removal-From-Play standard which ignores the ‘medical independence’ principle.
And Michigan’s Removal-from-Play new policy suffers from three other defects.
1 ‘Possibility of Concussion’: First, the policy fails to explicitly and repeatedly emphasize that the decision-making standard, for Removal-From-Play, probably should be significantly higher than the standard for ‘Return-to-Play. The Removal-From-Play standard must emphasize the need for removal where there is any possibility that a concussion has taken place. There are tremendous pressures, from that Mad Bull of Triumphs and Profits, to soften this standard; after all, Shane Morris remained in the game for another play, and was then re-inserted later, and those events all occurred at a point, some 11 minutes from the end of the game, when Michigan was desperate to mount a comeback from a 30-7 deficit.
2. Spotter Calls the ‘Fellow’? — A New Barrier to a Quick ‘Get Him Out of There’ Decision: Michigan’s policy regarding the communication from the ‘on-high’ Spotter, down to the sidelines makes no sense. The radio ‘call’, according to the policy, must be made to the ‘Fellow’ doctor, not the primary doctor. Let me explain: a read of the policy makes clear that the sidelines are packed with more horse-handlers than Churchill Downs and, apparently, each of the neurologists has a neurologist “Fellow” (which means he is at Michigan medical school on a “Fellowship”) working with him; this is, then, a fancy term for a doctor who is, despite his advanced other degrees, still in (very advanced) training. And this piece of the new Michigan policy envisions that this ‘fellow’ doctor will always be ‘near’ his supervising senior doctor, and will be able to adequately communicate with him.
But this odd set-up undermines the entire reason for placing the Spotter up high, by generating unnecessary delay — when time is of the essence. Suppose, in the Shane Morris example, the Spotter saw what was evident to most people — that Morris was incredibly unsteady on his feet — and radio-called down to the sidelines his conclusion that Morris must be immediately removed. That radio-call, according to the new policy — must go to the ‘Fellow,’ who then has the responsibility to relay the information to his supervising doctor. Let’s just assume also that the Fellow (and his ‘Supervising Doctor) were not (as is common) able to see the Morris hit or its sequelae, so that the Fellow is not only surprised, but also concerned by this call from up-above, because Michigan is down 23 points with only 11 minutes left in the game — and everyone in that stadium wants a comeback led by that quarterback. So he turns to his supervising Doctor (assuming that doctor is handy, which seems a bit of a jump), to then explain to that supervising Doctor the facts relayed by the Spotter. The supervising Doctor has the same surprised reaction, and the same c0ncern about an order to ‘pull’ Michigan’s quarterback at this late, dire stage in a hoped-for comeback. And this all takes time — in a situation where the next play will, in most case, quickly unfold. The policy, then, inexplicably creates an unnecessary communication hierarchy, which itself causes delay. The Spotter should have the duty and authority to communicate immediately with the supervising Neurologist to get the player off the field, if necessary.
3) The Michigan policy fails to spell out any standards which the Spotter must apply in making any recommendations or decisions about any need for Removal-From-Play. (Some of this need for clear standards might be satisfied by a sort of ‘bench memo’ of videotape examples of past plays where experts agree immediate removal is required.)
4) The Michigan policy should empower the Spotter to make his own quick but final ‘Get Him Out of the Game’ order.
In summary, the Spotter should be independent from, and not employed by, the athletic department; equipped and required to communicate directly and immediately with the Chief Neurologist on the sidelines; and authorized to make, on his own quick ‘Get Him Out of the Game’ order. And any Removal-From-Play decision should be based upon a decision that the ‘possibility of concussion’ appears, using standards which are explicit and widely available.
Particularly because of the Morris incident, but also because of Michigan’s dual ‘flagship’ status as a major college football power and pre-eminent medical center, Michigan’s new policy regarding Removal From Play misses the mark. As it now stands, Michigan’s ostensible commitment to the principle of ‘medical independence’ has lost out to the de facto Mad Bulls of Triumph and Profit.
If there exist substantive reasons, according to the concussion protocol drafters, as to why they chose to use a Spotter who is an athletic department employee, who must call to an intermediary medical person on the sidelines, and who does not have ‘Get Him Out of the Game’ decision-making authority, then the drafters should explain why those choices were made. And the policy needs more explicit standards as to the kinds of ‘triggers’ which require exercise of Removal-From-Game authority.
Smaller schools and high schools will ‘benchmark’ their concussion-management policies against Michigan’s. Michigan needs to fix these defects.