NHL's concussion protocol can leave players vulnerable

Even if you know nothing of Sidney Crosby's concussion history, seeing him careen head-first into boards last night was unsettling.

Crosby stayed down for a few moments before slowly getting back to his feet and gingerly rejoining the play. After watching the replay and seeing Crosby's head smash into the boards, the questions on everybody`s mind were obvious.

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Had the face of the NHL suffered another concussion and his second in less than a week? Surely the NHL's enhanced concussion protocols, introduced at the beginning of the season, would force Crosby from the game.

But as we are learning today, those protocols can often be confusing, and on occasion, may be leaving players vulnerable.

The protocol states the "identification and removal" of players for "acute evaluation for possible concussion" is the team's responsibility.

What happened after Crosby was hit late in the first period is murky. Capitals head coach Mike Sullivan initially told reporters doctors didn't evaluate Crosby for a possible concussion. On Tuesday, Crosby told reporters he was in fact examined by a team doctor during the first intermission and didn't have to enter in the concussion protocol.

Crosby 'aware of risk'

Dr. Nelilank Jha, a Toronto based neurosurgeon who has consulted with the NHL, believes player input is important.

"At the end of the day let's not forget, if Sidney Crosby doesn't have any symptoms, they evaluate him, he passes that baseline test, which is not a perfect test," Jha says. "If he decides he wants to go out there and play it's his choice once he is aware of the risk."

There are six scenarios that could lead to an NHL player being removed from a game to be evaluated for a suspected concussion.

The protocol says a player should be evaluated for a concussion after a direct or indirect blow to the head if they exhibit symptoms that include headaches, dizziness and nausea.

Crosby was never removed from the game but it appears he was evaluated after reporting or exhibiting some of the listed symptoms.

Jha says a number of factors would have led doctors to allow him to play.

"I see a couple of hundred concussions a week and am keenly aware that even if you have a history of concussions it doesn't necessarily mean that if you hit your head or take a blow that you will have another concussion," Jha explains. "Also knowing Sidney Crosby, I have the confidence in him that if he were symptomatic he would take himself off the ice. Think about it from his perspective, he doesn't want to suffer for a year and half again."

Other criteria for an immediate concussion evaluation include: a player "lying motionless on the ice," having "motor incoordination/balance problems, "blank or vacant look" or is "slow to get up or clutches head."

It's the last one that's confusing. It appears Crosby was slow to get up so why wasn't he immediately removed?

The list

The "slow to get up or clutching head" protocol only applies if the blow to the head is from "another player's shoulder, the player's head makes secondary contact with the ice or if the player is punched by an ungloved fist during a fight."

Crashing headlong into the boards is not on the list. The protocol says that if it's not one of the above scenarios," removal from play is not mandatory and the club's medical staff shall exercise their medical judgement," whether to remove a player for evaluation.

"Depending on the mechanism of injury, 'slow to get up' does not trigger mandatory removal," NHL deputy commissioner Bill Daly tells USA Today Sports. "The protocol has to be interpreted literally to mandate removal.  'Ice' as opposed to 'boards is in there for a reason. It's a result of study of our actual experiences over a number of years. 'Ice' has been found to be a predictor of concussions- boards have been."

"They need to revise that document," Dr. Jha says.

But more importantly, Jha says the league should turn its attention to the spotters, who were introduced this season to enhance player safety. Every game is monitored by spotters stationed in the league's player safety room in New York. Those spotters have the authority to remove players from a game for evaluation under the league's concussion protocol. A number of in arena spotters were also brought in to help the league's staff in New York.

As we saw last night, even if the league spotter had noticed something off with Crosby after the hit, a removal, under current league rules, wouldn't have been permitted because Crosby's head hit the boards and not the ice.

"I think the job of the spotter is extremely difficult," Jha says. "Do I think when the NHL reviews this they are going to revise and improve their policy? I would say yes. If you hit your head against the boards and there could be a suspected concussion that should fall within the jurisdiction of the rules."

Even so, Jha says the task of spotters presents challenges.

"That job would even be difficult for me. If I see somebody get hit, I can't determine based on the way the hit was whether they had a concussion or not and we can't expect the spotter to," Jha says. 

"You could hit your head very hard and not have a concussion. You could also not hit your head and have a concussion. So when we are relying on a spotter with no objective medical test it's going to be an imperfect system."