Concussion Update (Part Seven)

I first posted about Concussions in football on 8 August 2014.  My last concussion update was in October.  I think I stopped posting on the subject because it felt too much like banging my head against a wall.  (My six earlier posts about concussions can be found here, here, here, here, here, and here.)

In my first post, I discussed the new rules dealing with head injuries and wondered “whether those new rules are adequate or whether the pre-existing state of denial will just continue.” The events of last season and the clash of heads between Olivier Giroud and James Tomkins in the Arsenal—West Ham game last Sunday demonstrate that for all the big talk, the denial continues and the Premier League does not take this issue seriously.  Players are not being properly evaluated and removed from play even when they have suffered apparent serious head injuries.  The recent events involving the Chelsea team doctor, Dr. Eva Carneiro, and the way she was treated by Jose Mourinho and the management of Chelsea compound the problem.

 

The most critical aspect of the protocol for head injuries is that the decision as to whether a player with a head injury can continue must be made by the doctor, not the player or the manager.  It is difficult to see how any team doctor can take this rule seriously given what has happened to Dr. Carneiro.

 

Based upon an apparent injury to Eden Hazard, she and Chelsea’s head physiotherapist, Jon Fearne, ran onto the field—at the referee’s request—to provide treatment.  This was a medical decision.  Yet, as a result of that decision, they have both been demoted.  (See here.)  This sends a clear message to all club doctors that they can be punished for doing their job. 

Mourinho found fault with Dr. Carneiro and Fearne because their actions did not demonstrate a proper understanding of the game.  In an article on this incident Martin Samuel agrees and also lets us know that sexism was not involved.  (See here.) 

Apparently, Hazard was not really injured, he was just tired and taking a rest.  Mourinho could tell all the way from the sidelines that Hazard’s rolling around in pain was fake and he expected his doctor and physiotherapist to reach the same conclusion.  Mourinho’s claim is, on its face, preposterous.  Setting aside the fact that this means Hazard was cheating, his behavior was convincing enough that the referee gestured, twice, for the treatment team to come onto the field.  Mourinho may very well have hoped that Hazard was not seriously injured and was just resting and stalling, but he could not be certain.

 

The problems that could arise in the case of a head injury are clear.  What happens if, in a future game, the Chelsea team doctor (either Dr. Carneiro or her replacement) decides that the player needs a full evaluation to determine whether he has suffered a concussion.  This could keep the player off the field for ten or more minutes if done properly.  Yet Mourinho believes that the doctor is obligated to understand the game and, presumably, get the player back on the field as soon as possible.  Under such circumstances, Chelsea’s doctor and, perhaps, doctors for all the other Premier League teams would know that they are expected to conduct their concussion evaluations rapidly and without regard for the true medical needs of the player.  In fact, this pressure might explain why team doctors are already allowing players with head injuries to go back into play so quickly. 

 

In Dr. Carneiro’s case, there are other factors potentially at play because she is a woman.  Allegedly, there have been concerns expressed by Mourinho because, supposedly, some players were not happy that there was a woman doctor with access to the dressing room.  On the other hand, The Times claimed that this was not true.  (See here.) There have also been claims that the last straw causing her demotion was not her decision to run onto the field but her Facebook post thanking the public for their support.  (See here.)   According to a Guardian article written by David Hytner, Mourinho demands total loyalty and privacy from the staff at Chelsea.  The Facebook post while not actually violating Chelsea’s rules, violated Mourinho’s unwritten rules.

 

Another Guardian author, David Conn, (see here) suggests that by stripping Carneiro of her match day and training session duties, Chelsea has constructively dismissed her and Chelsea could well be sued.  Conn points out that with Hazard on the ground and in pain and the referee beckoning to the Chelsea bench for attention, “Carneiro could have been in serious breach of her professional duties as a doctor had she not attended to him.”  That much seems self-evident.

 

Not surprisingly, the Premier League Doctors Group has condemned Chelsea’s treatment of Dr. Carneiro.  I am unable to find the exact text of their statement.  (One article for which I have misplaced the link, claims that this is the first public statement that group has ever issued.)  Other doctors have also spoken out in defense of Dr. Carneiro.  On the other hand, Chelsea’s last team doctor has publicly criticized her and supported Mourinho.  (See here.)  Possibly he wants his old job back.

 

Obviously, we cannot know if sexual discrimination is involved in Chelsea’s treatment of Dr. Carneiro. However, it seems a likely possibility.  We do know she has been subject to abuse simply because she is a woman doctor for a Premier League football club.  (See here and here.)  Certainly, sexism is the most logical explanation for why there is only one woman doctor in the Premier League.  After all nearly 45% of the doctors in the United Kingdom are women.  (See here.)

 

While no one has asked me, if I were the Premier League Doctors’ Group I would demand that Mourinho be sanctioned severely and publicly apologize and that Dr. Carneiro be restored to her job.  If that did not happen, I would organize a surprise work stoppage for a weekend of Premier League football.  Since team doctors are required for games to be played, this would cause the cancelation of an entire weekend’s worth of football.  On the other hand, I am not an expert in English Labor Law so it may well be that it would be illegal for the doctors to organize this kind of action.  Nevertheless something should be done and if that something does not result in Dr. Carneiro being restored to her job and Mourinho being appropriately sanctioned, it is not enough.

 

Bringing this back to the subject of concussions, in Sunday’s game Arsenal’s Giroud and West Ham’s Tomkins butted heads.  On my initial viewing, it looked like they were both unconscious which made it seem strange and completely inappropriate that they were back in the game barely three minutes later.  However, I reviewed the incident multiple times and I do not think there is any evidence that either player actually lost consciousness.  I will lay out the timeline of the incident.  Note that this timeline is not complete because the television coverage spent a lot of time replaying the incident or showing something other than the two players lying on the ground.

73:55     The incident occurs.  As he is going down, Tomkins moves his hand to his head.  Giroud starts to move his hand to his head but then stops.  This suggests to me that both players were still conscious immediately after the collision.

 

74:00     Both players are on the ground not moving.  The referee is looking at the ball in play and not at the players on the ground.  From this I infer that  the referee is not yet aware of the incident.

74:03     The referee blows his whistle.  Neither player is moving. 

74:09     Giroud is tipped onto his side by one of his teammates and appears to move on  his own slightly while this is happening.

74:50     Although still on the ground both players appear to be making slight volitional movements.

75:50     Giroud gets up and walks off the field.

76:05     Tomkins gets up and walks off the field.  He is helped by medical personnel and  appears to be unsteady on his feet or, to use the technical term, woozy

77:10     Both players are back on

Subsequently Arsenal issued a public statement that Giroud never lost consciousness.  From my repeated viewing of the game on the NBC coverage of the game, which included multiple replays of the incident itself, I do not think anyone can be sure whether either player lost consciousness so if Giroud says he never lost consciousness, he probably did not. 

On the other hand, it is clear that both players suffered a head injury and, whether they lost consciousness or not, could have suffered a concussion.  That is why the handling of the incident once the players were off the field, was problematic.  Medical personnel were in contact with the players for no more than three minutes before they were allowed back onto the field.  As I have stated in earlier concussion posts, it is simply not possible to do an adequate assessment to determine whether someone has suffered a concussion in that about of time.  If, indeed, the team doctors made the evaluations and cleared the players to go back on the field, I find it difficult to believe that they were complying with their medical duties to put the health of their patients first.  Very possibly the doctors felt pressure to get the players back on the field as soon as possible and knew that they would not be given the time necessary to conduct a full concussion assessment.  The pressure on the second doctor to let his player back on the field after the first player returned might have been particularly strong since otherwise he would be demonstrating his lack of understanding of the game by forcing his team to play one man short.

 

In researching this issue I found this article which discusses how long it takes to determine whether a concussion has occurred.  It describes the Standardized Assessment of Concussion Screening Tool which take five to seven minutes to administer.  Here is a link to the scoring form.  According to the article, it identifies the concussions correctly in 90-95% of the cases when there is no loss of consciousness or other signs of concussion.  Thus, even this tool would allow a significant number of players, over the course of a season, to continue to play with a concussion.

 

A more sensible rule would simply be to say any player who suffers a head collision and does not immediately get back up on his own must be removed from the game.  (This would not be necessary, of course, if football adopted the proposed rule change that would allow a temporary substitute while the player is fully evaluated for concussion.)

 

I also reviewed this more scientific article analyzing the Standardized Assessment of Concussion Screening Tool.  The article contains statistical stuff I did not understand because I did not take statistics in college.  However, the article makes it clear that the test is not a pass/fail exam where, if you score a certain score you do not have a concussion.  Instead, the results must be compared to the individual player’s preseason baseline score.  Players who have not suffered a concussion typically score at the same level or slightly better when tested during the season.  On the other hand, players who have suffered a concussion did not improve their score.  A small number of them scored the same but most of them dropped a significant number of points.  The article concludes that persons who suffered concussion usually displayed a decrease of more than four points on the exam immediately after the concussion whereas uninjured players averaged an increase of just under one point.  The suggestion appears to be that any drop from the preseason baseline is highly likely to correlate with the existence of a concussion but the greater the drop the more certain is that conclusion.

 

Obviously, neither doctor at the Arsenal—West Ham game conducted this thorough of an assessment because they, quite simply, did not spend enough time.  Arsenal later claimed, very likely correctly, that Giroud had not suffered a concussion.  West Ham chairman David Gold tweeted that Tomkins was bruised but happy with the result of the game, presumably implying that he had not suffered a concussion.  However, the results do not justify the means.  Given the information that is publicly available about concussions, the effects of concussions, and the process of assessing concussions, there is simply no way that anyone could have known that neither player was concussed when they returned to the field of play.  In other words, as I stated last season, the new concussion protocol is a farce.  It is designed to make the Premier League (and the FA) look like they are behaving responsibly by taking appropriate steps but that is not what is actually happening.  Moreover, after what happened to Dr. Carneiro, it seems difficult to imagine that a team doctor can feel confident in exercising independent medical judgment to keep a player from reentering a game if the player is conscious and wants to play.

 

The Premier League should fix this problem.  The best solution would be to assign independent doctors to make the mandatory concussion assessments.  Any player who has suffered a head injury should be evaluated by the independent doctor some distance away from the bench area to avoid improper influence and to give the doctor enough time to conduct a thorough evaluation.

 

It would also make sense to change the substitution rules so there is time to make a concussion assessment, while another player goes on the field temporarily to replace the injured player.  If the league does not want to tinker that much with football’s traditional three substitution rule, the league should enact a mandatory removal from the game rule for persons with head injuries.  If they are not going to make any of those changes they at least need to do something to protect Dr. Carneiro and other doctors from being punished by their club when their medical judgment does not meet with the approval of the on field manager who, at least in Mourinho’s case, believes it is more important to avoid losing a game than it is to ensure the safety of his best player.