According to NFL Chief Medical Officer Dr. Allen Sills, M.D., the most important part of any NFL game day – whether it's a preseason or regular season game, an international game or the Super Bowl – happens in a small room inside the stadium about an hour before kickoff.
A group of 20 to 25 people representing a wide range of medical backgrounds meets in the X-ray room next to the home tunnel at Huntington Bank Field to discuss the variety of safety measures that will take place on game day.
"It's a lot like what happens in an airplane cockpit right before takeoff," Sills said Oct. 27 of what is called the "60-minute meeting." "No matter how many times the pilot has done that takeoff, they're going to go through the checklist to make sure that everything is done."
At the 60-minute meeting, medical personnel go over the safety protocols put in place and introduce themselves to each other as well as the head referee, so that the game officials can be familiar with the personnel running onto the field when a player suffers an injury.
Each team fields a staff including a team physician and medical trainers. Additionally, the NFL hires independent medical staff – including spotters, unaffiliated neurotrauma consultants, emergency doctors and paramedics – to ensure that athletes are treated quickly and effectively after sustaining injuries.
"Both of those medical teams are all in here to provide the safest environment for the athletes," Browns head team physician Dr. James Voos, M.D., said. "So, with that visiting team – who may not have been here before – if there's an unfortunate injury, we want to be here to support their medical team and help that player to get the exact same type of care that they would get back in their home stadium. So that's really the goal, is to standardize that level of care."
The level of care has drastically improved as the expanding worlds of medicine and technology further interact. When a player goes down, it's not just the on-field medical personnel responding to the injury. Spotters up in a booth will review the play using an average of 16 different camera angles of replay – depending on the stadium – radioing down to the on-field personnel with their evaluation of the injury. Medical personnel located on the sideline also have access to a replay booth, where they can review the play in question to provide the best possible diagnosis in real time.
After a player is injured, they are typically taken to the blue medical tent located on the team's sideline, unless the injury is severe enough to necessitate the player being brought straight to the X-ray room, locker room or a pre-determined local hospital.
The blue medical tent was first introduced to the league in 2017, inspired by the University of Alabama's usage of the tent beginning in 2015. Alabama Director of Sports Medicine Jeff Allen came up with the idea to limit distractions and provide privacy for injured players.
"This is like being in your doctor's exam room as opposed to being out in front of 70,000 of your closest friends," Sills said. "So, it's just a chance to have a little private moment. I think, even though, again, we're on the sideline, we're in the stadium, this becomes a much more peaceful place, and you can do a good medical exam."
The nature of the injury and necessary medical examination dictates the personnel present in the medical tent during an injury evaluation.
For non-concussions, typically only the team doctor and in some cases an athletic trainer are present alongside the athlete.
For a concussion, the unaffiliated neurotrauma consultant – who can be identified by their red hats – enters the tent along with the team doctor and possibly an athletic trainer. No coaches are allowed in any instance into the blue medical tent.
Once a concussion examination begins, it could be a matter of minutes before the player is able to return to the game. According to Sills, for every positive concussion test, three to four concussion tests are negative, and the player is able to return. If, however, the player is suspected to have suffered a concussion, they are taken to the locker room for further evaluation.
Sills addressed an important aspect of concussion evaluations regarding the presence of the team's head physician. While some may express concern of a "biased" opinion of a doctor who is perceived to have a vested interest in a player returning to the field, Sills emphasized the importance of being familiar with a player's typical mannerisms when diagnosing a concussion.
"If I am an independent doctor, I don't see that player every day. Sometimes one of the only signs of a concussion is that they're just not right. They're just not themselves," Sills said. "And the doctor who sees them all the time, or the trainer will say – and I've seen that many times through my career – where they said, 'You know what? They're answering every question the right way, they've passed every test, they've walked the line but they're just not right.' And that is an incredibly valuable piece of information that will make us hold them out and diagnose them."
A wide number of people can initiate a player being tested for a concussion, from coaches, players and trainers to the unaffiliated neurotrauma consultants (UNCs). If there is a disagreement between the team doctor and the UNC on a player's concussion diagnosis, league policy mandates that the player is subjected to the most conservative diagnosis.
Once a player is diagnosed with a concussion, they exit the sideline and enter the locker room, where a member of the medical staff stays with the player to ensure no further medical treatment or hospitalization is necessary. Even if a player gets a negative concussion evaluation on game day, the player is checked for symptoms 24 hours later.
Concussion symptoms can be delayed and not immediately recognized after the initial contact.
"It really happens more globally," Voos said. "A player may bang knees with someone in the game and not think anything of it and not report it. When they come in, overnight their knee swells up and they come in the morning and their knee is swollen. So, in a similar way, those (concussion) symptoms can evolve. I think the protocol is more designed to be more broad. We'd rather examine more people and them be negative, we'd rather over screen."
Whether it be mastering concussion protocol or handling the myriads of other injuries that occur on the football field, working on the medical staff at an NFL game requires a yearlong commitment in order to provide the best care for athletes.
Voos said that throughout the year, teams and league officials review their injury protocols and practice both at the stadium and at team facilities in preparation for each season.
"We review these emergency action plans multiple times through the year. So, it's not just when the season starts. Before the season, we practice these emergency action plans here at the stadium. We also practice them at our facility in Berea, because emergencies can happen there as well," Voos said. "So, across the league, all 32 teams, we all do standardized emergency action plans. We all sign off that we've gone through all of those scenarios again. That way, on game day, you can replicate that level of safety for every player no matter what environment that you're in."
