The most explosive ongoing story of the NFL season has nothing to do with quarterback play but rather how and why a quarterback was allowed to play.
On Sunday of Week 3 (Sept. 25), Miami Dolphins QB Tua Tagovailoa left a game against the Buffalo Bills after taking a hit and appearing to be disoriented as he got to his feet and walked off the field. He later returned to the game after clearing the NFL-mandated concussion protocol.
On the Monday following the game, he was diagnosed with a back injury and the NFLPA opened a review on the handling of the injury by the team.
On Wednesday of that week, he was listed as questionable for a Thursday night game with a back and ankle injury.
On Thursday, Sept. 29, he started against the Cincinnati Bengals before leaving the game with another concussion sustained in an eerily similar fashion to the first — the back of his head slamming on the ground after being hit. Tagovailoa remained lying on the field for approximately 20 minutes.
NFL chief medical officer Dr. Allen Sills said that Tagovailoa was checked for concussion symptoms every day last week before an independent neurologist cleared him to take the field on Sept. 29.
That independent neurologist has since been fired.
On Tuesday, Tagovailoa spoke with the NFL and NFLPA about their ongoing investigation. He’s been ruled out for Sunday’s game vs. the New York Jets.
While it’s too late to change how Tagovailoa’s injury was handled, the NFL needs to understand why it happened so that the league can learn from it and avoid similar situations in future.
Given the league’s history with the handling of brain injuries, there needs to be a further examination of the process and continued conversation around the culture.
As part of the process, the sideline checklist of the concussion protocol currently consists of a player being ruled out by a team physician and neurotrauma consultant for displaying loss of consciousness (including impact seizure and/or fencing posture), gross motor instability (neurologically caused), confusion or amnesia. And that is followed by a locker room exam.
The NFL is expected to implement changes to their protocols as early as Week 5 -- this week.
But then there’s how the culture of the game looks at concussions. As a university football player, I remember thinking that ‘concussion’ is not a strong enough word to describe what it is. We’ve become desensitized to it. We should call them what they are: severe brain injuries.
Thus, we need to treat athletes as patients, not just players, when they show signs or symptoms of a concussion. Players are conditioned to ignore pain and get back on the field to play through injuries and help their teams win.
For that reason, coaches are paramount to addressing the culture. Ultimately, coaches have the final say on who gets into the game so they are the last line of defence when it comes to protecting players. The medical professionals are there to assess the situation and allow the coaches to make informed decisions, but they should also be able to rely on common sense.
To better understand what went wrong and why better awareness around this issue is critical, I spoke to Dr. Charles Tator, professor of neurosurgery at the University of Toronto, the director of the Canadian Concussion Centre at Toronto Western Hospital, and a member of the Canadian Medical Hall of Fame and Canada’s Sports Hall of Fame.
(Editor’s note: This interview has been edited for brevity and clarity)
Sportsnet.ca: What did you see during the first blow to the head Tua Tagovailoa suffered that concerned you?
Dr. Charles Tator: When he was thrown to the ground and then, when he got up, he stumbled. The behaviour that he showed is what we want to teach people to recognize. Instability or, as some people call it, staggering.
A whole bunch of words are used to describe it. In the NFL protocols, it’s referred to as gross motor instability and that is a definite sign of concussion. In my view, anybody who shows that sign of concussion should be considered to have had a concussion, and you remove them from the game.
The fact he appeared as a player in the second half, that was really a bad decision to let him return to play.
SN: Was this a failure of people or a failure of process?
CT: Well, those are really good questions. Here's my view of it: It costs the NFL a billion dollars to settle the lawsuit by the players for the consequences of concussion. So, as a result of that, the NFL has tried — very hard in my view — to come up with a good mechanism for handling concussions.
When you carefully examine that protocol, which is very detailed and you can look it up online and see all the items that are listed, the thing that I like about what they've done is that they've been very open about trying to tackle this problem. Not only for the money aspect, but I really think they now want to preserve the brains of their assets and that is their players.
[In this case] it simply failed. The system failed to recognize that Tua had a concussion. So why did the system fail? Well, the two people who are responsible for deciding if something was a concussion are the team doctor for the Miami Dolphins and the unaffiliated neurotrauma consultant. They fired [that consultant], and I think they were right. They haven't announced what they're going to do to the Miami Dolphins team doctor.
SN: It’s one thing to make one initial mistake in the moment but after you’ve seen the replays all week, how do you make a second mistake to play him on a short week? What are the dangers of second impact syndrome in a situation like this?
CT: That's really an important question. The consequences of missing it are that the player can then go on and get another concussion and have the horrible complication of that other concussion, which is death.
If it's missed, you can die from a second impact. It takes time for the brain to rest after a concussion before it gets another one. We know that concussions are cumulative. We've known that for a long time. Concussions have a cumulative effect on the brain, so that's why it's so important to recognize when someone's had one, because it's a setup for death.
It doesn't happen to too many, fortunately. The number of confirmed cases of second impact syndrome is less than a hundred. Unfortunately, in Canada, we've had the experience of Rowan Stringer, who is our classic example recently in 2013 when she got her concussions and then died from major brain swelling, which is a consequence of repetitive concussions.
We did have a previous case in Canada in the 1960s, of a young hockey player who also died of second impact syndrome. The cases in Canada have been few but certainly we have to keep that in mind as something to prevent because it's totally preventable by preventing the second concussion.
That's the acute consequence. And then the long-term consequence of repetitive concussions is CTE, so that's the billion-dollar cost to the NFL.
CTE is also, fortunately, turning out to be rare. It does happen. Many people say it doesn't happen, that it would've happened to those people anyway, but that's not true. CTE is a real consequence of repetitive concussions, and it usually doesn't happen for many years.
SN: Concussions are unlike many other injuries, as there is no definitive diagnostic test that shows exactly what you're dealing with in the way you can for an ACL tear or hamstring pull. Is their advancement in the science that can close the gap on some of those challenges?
CT: Those are great questions, and the answer is that we don't have any. The whole world of scientists is looking for a biomarker. Nowadays, we talk about a biomarker, which is a good word because it indicates some biological evidence that will mark that this has happened. The best example is for heart disease. If you go to the emergency department, one of the first things they will do is take a blood sample. If you have signs of a heart attack, there are components in the blood that show up to prove that you've had a heart attack, and it's a good test. We don't have that for a brain injury of any sort.
We're behind in discovering the types of biomarkers. There are two main types, and one is a biofluid biomarker. That means you can detect it in either blood or saliva or spinal fluid.
There have been a lot of studies done in the last, at least, 20 years. People have been looking for reliable biomarkers in bio fluids, and we haven't found one. So that means [we rely on] ordinary X-ray, CT scan, MRI.
The whole world has been looking for it, including us, and we haven't found it. We think we're getting closer, but closer isn't good enough. You have to be definite. What we're left with is the same thing that we had probably 25 years ago now, when we started to be concerned about concussions. We're still left with the symptoms and the signs. Believe it or not, we now recognize about 85 symptoms of concussion, but virtually none of those symptoms is specific.
You can get the same symptoms from other conditions like the flu, for example. COVID is causing some of the same symptoms as concussion. Migraine headaches can produce quite a few symptoms that overlap. So, the symptoms are not as specific; they're suggestive, but that's all we have.
SN: Because of that, we rely on baseline testing which players can try to manipulate.
CT: Baseline is useless by the way. For kids especially, it's useless because the growing brain, you'd have to give a kid the test about every three-to-six months to know that it's going to be stable. And there are so many factors that can interfere with the effectiveness of baseline testing. We never endorsed baseline testing for young people. My overall impression, especially for making the decision at rink side or at field side, is that the baseline testing is useless.
SN: Is it to too easy to say that, if someone has a second concussion, they should be done for the season?
CT: We have a pretty good way now of assessing whether somebody is ready to go back to play. It still does depend on the cooperation of the person, and that's the other point that we haven't discussed, which comes under the heading of compliance.
You mentioned players fudging their baseline tests so that any deficit doesn't show up. That's part of compliance, too. And we know that there are incentives and the desire to play; you as an athlete know that yourself. The players like to play, as Ken Dryden told me. So, they're motivated whether they're in high school, or whether they're in university, or the NFL, or the NHL — players like to play and to say they can play. They do everything they can possibly do to play and that clouds their judgment of when they're ready to play. So, when you're examining players, you have to take that into consideration. There's a skill involved on the part of the examiner to make sure that they are compliant.
And sometimes you blow it. That's why we differentiate signs, [because] signs you can't fake. He showed gross motor instability. He's going to try to minimize it, but he can't get rid of it completely because the brain isn't working. That's why the signs are very important. If somebody has lost consciousness, that's a definite sign. If you vomit afterwards, you can't play. That's a definite sign. The signs are more reliable.
The symptoms depend on the person's compliance. In other words, if he or she is going to reveal that they’ve got a headache or dizziness.
SN: After Tua’s second hit in Cincinnati, much was made about the fact that he flew with the team back to Miami and the coach mentioned that they both were watching a film. Screen time seems like something you'd want to stay away from. What sort of best practices do you need to have after a brain injury?
CT: This is definitely an evolving field, how to manage concussions. We do know a lot more than we used to know, so quite a bit has been discovered. If you have 30 or 40 symptoms, sometimes you need specific treatment for each one of them. We now know that to make a real dent in recovery from concussion, that it often takes a multidisciplinary team of healthcare professionals.
On the other hand, it has to be individualized care because no one size fits all. No one has all 85 symptoms. Whatever group of symptoms a player has, that's what needs to be treated — if they have a headache, or if they have computer screen intolerance, or if they have vertigo, or if they have difficulty sleeping, or depression, or anxiety, or PTSD. That's why it's so difficult with some people to get the concussions treated. And as you know, it matters how many you've had. So, the recovery after your first concussion is better than your recovery after your 10th concussion.
SN: The NFL and NFLPA are looking at amending the protocols. What advice would you give them on how they can be improved?
CT: The only thing I would add would be video demonstrations of the items that they really want these doctors to look at. It's not really necessary to do a video display of symptoms, but you could certainly do a video of signs of concussion.
And then the other thing we haven't discussed is the sign that he did show after his second concussion where his fingers were in a peculiar extension position. They call it the fencing position. That is also a definite sign of at least a concussion, and it usually signifies an even more severe brain injury than concussion. That's why I was so concerned about missing his first concussion because the second one looked to me to be more than a concussion. They said that the MRI was negative, but I don't know how clear it was. I wouldn't mind seeing it.
I think it's a great opportunity to learn, and I think that the NFL's going to take the opportunity to make some changes.