Jordan McNair’s Death: Human Errors, Checklists, and Need for Radical Change


Jordan McNair’s death at Maryland football tells us that something is very rotten in college football safety; top-to-bottom change is needed. Some random thoughts:

1. Is there an App for that? Jordan McNair’s life would have easily been saved, had there been a 7 year old kid there, able to tap a cellphone app, to pop up the quick-and-dirty checklist for handling heat exhaustion. Atul Gawande revolutionized medicine, and slashed medical error rates, by insisting upon use of basic, simple checklists to be applied, not just in surgery, but in clinical and other situations. Gawande’s great accomplishment was finding simple ways to eliminate predictable, recurring human errors. Medical and injury practices in college football need similar checklists.

2. Change the Hierarchy for diagnosis and treatment of football injuries: Gawande not only insisted upon checklists; he has been responsible for the other revolution in the provision of medical care: change the hierarchy. Surgeons, for example, used to run every surgery with an iron fist, so that everyone was afraid to speak up to make suggestions or corrections. Gawande changed all that: now the surgery has a protocol, with numerous checklists, with one person assigned to check-off each list. And if the surgeon doesn’t want to go along? — he is sanctioned, and not allowed to perform surgeries. (A similar hierarchy ‘shift’ has taken place in airplane cockpits, so that the Captain no longer has unbridled authority to rule: job descriptions have been changed to breed a more collaborative approach, in which the captain is required to review basic checklists.) Any medical or injury treatment in football conditioning, practices, or games, needs a similar revolution. For example, when Maryland trainers or others yelled to drag McNair off, or when a coach repeatedly berates a player for not being tough enough (as happened repeatedly before Ted Agu, a big lineman, collapsed and died in the heat at Cal), there should be a person there who can tell the coach to shut up and back off, so that the checklist can be followed. An oversimplified lesson to be drawn from the McNair death is that Strength and Conditioning coaches need adult supervision — though the accuracy of that conclusion is tested by the fact that adult head coach D.J. Durkin was on premises when McNair collapsed — driving the conclusion that even head coaches like Durkin need adult supervision.

3. Stop requiring large lineman like McNair to do ten 110-yards sprints: McNair’s death, alone, should cause a complete revamp of the way behemoth lineman practice. (There are plenty of other examples, too: Agu at Cal, Korey Stringer, O’Neal at Mizzou.) The science and practice of conditioning those large athletes should be specially designed to recognize that they are never required to run 110 yards in a game, and that their play-by-play exertion tends toward power-based footwork along the line and, short 10 or 15 sprints. I’m no exercise physiologist, but these coaches who make every lineman do those 110 x 10 sprints are knuckleheads. Get rid of ’em.

4. Stop Pretending S&C coaches are ‘Not–Coaches’: S&C coaches should not be exempt from the NCAA CARA and other time/contact restriction imposed on all other coaches. Tell them to go home and learn to knit during the off-season. Let the players who want to lift on their own do it.

5. Resurrect the off-season: NBA, NFL, and MLB players all have a number of months during which the owners have no control over, or contact with them. College sports should create a mandatory 90-day off-season, during which contact with the player is proscribed. Over the last 40 years, coaches have evolved from seasonal coaches, into mad-men who insist that the drug which is their sport must be injected every day of the year. (Unfortunately, even many of the ‘Non-Revenue’ sports no longer have any off-season — solely because athletic directors have arbitrarily decided to measure their own performance, and that of other AD’s, by Learfield/Director’ Cup ranking.)

6. Create a Medical Ombudsman position, for football: Each school should appoint a player’s Medical Ombudsman, paid for by the school, but independent of the school, with a duty of confidentiality which runs only to the player. This person would serve to receive reports, and consult with, each player who seeks that kind of advice or consultation. (Erik Burkhardt, one of the most competent and respected agents for NFL players, says he spends fully one-half of his time handling the many medical issues which his clients confront in a dangerous sport.)

7. Create a Legal Ombudsman, for football and basketball: This similar position, paid for by, but independent of, the school would give player a confidential source for legal consultations of all kinds. Though schools and they NCAA like to pretend otherwise, the average big time basketball and football player confronts many legal issues throughout the year.

8. Require that medical staff for athletes be hired and employed by (with reporting duty to), non-athetic department personnel. Maryland President Loh, when faced with this logical recommendation a year ago, rejected it.

9. Require that conferences play a significant role (and spend significantly) in Player Safety: Conferences have devolved into media-rights brokers; they also have massive income. Some substantial portion of those budgets should be devoted to player safety. Imagine if the Big Ten had hired some geek sophomore at, say, Iowa, to design and implement an app which provided Gawande-type simple pop-up screens, with basic 5-point instructions for handling the top ten emergencies in football? It might’ve cost the Big Ten $2,000. And McNair would be alive today. (The same logic applies to the NCAA.)

10. Require the NCAA to establish medical-treatment and injury-prevention standards. The reason the NCAA now refuses to set standards is that it wants to avoid liability. That cost-avoidance jumpiness may be proper for-profit ventures — but not for a non-profit like the NCAA, which also broadly pronounces that its #1 concern is the “welfare of the student-athlete.”

11. Make UnderArmour take a role in player safety: Jordan McNair was on UnderArmour’s advertising staff. Every big-time NCAA football and basketball player works as a (very valuable) advertiser for Nike, Adidas, or UnderArmour. McNair, I am quite sure, collapsed while advertising for UnderArmour, since he wearing their gear. UnderArmour should step up and commit to providing — and developing, with Maryland, — the most sophisticated wearable tech apparel which might help monitor and prevent heat-exhaustion.

12. Post “Safety First” signs everywhere on the football workout complex: In some ways, college football is no different than a construction site: both have not only an ever-present risk of many different kinds of injuries, but also the risk of life-threatening injury. And, just as at construction sites, signs should be placed everywhere dictating “Safety First.” The entire paradigm needs change. There must be some schools which do it all better than Maryland, but the Maryland fiasco is a canary indicating that big-time college football safety programs are stuck in 1960.

13. Penn State/Mitchell Report “Athletics Integrity Program” was to be applied to the entire Big Ten – and all safety issues, not just pedophilia: All Big Ten members signed onto that Athletics Integrity Program (even AD Mark Hollis at MSU). And, contrary to popular belief, those practices mandated by that program applied to all safety issues, not just pedophilia. Those included Team Monitors, an Athletics Integrity Council and Officer, and creation of a system for reporting by a player to a source outside of the athletics department.

The whole paradigm for preventing injuries and deaths for college football players needs radical change. They were needed, in fact, after Ted Agu died at Cal. Why did McNair die? Because athletic directors, presidents, conference executive directors, and the NCAA did not care to act to make changes.

About brewonsouthu

lawyer, with interest in college sports and NCAA oversight and decisions, and sports generally.
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