In our Ask a Doc series, we sit down with physicians and other clinical experts across Highmark’s health plan networks, including at Allegheny Health Network (AHN), for a chat on an important health topic. In this post, AHN’s Dr. David Jho discusses his work as an NFL neurotrauma consultant at Pittsburgh Steelers games.

The tackles, the sacks, the mid-air collisions — football is anything but a tame sport. While this makes for an exciting autumn afternoon, football’s high-impact hits also make concussions a serious concern.

In response to such concerns, the NFL created a Concussion Diagnosis and Management Protocol in 2011. One part of the protocol is to have Unaffiliated Neurotrauma Consultants (UNCs) at each game. UNCs work in conjunction with NFL team physicians to improve the diagnosis and management of concussions, but they are also independent of any team. Among other things, the UNCs are empowered to call a medical timeout if they suspect a player requires medical attention for concussion-like symptoms.

Two UNCs are present at every NFL game — one on each team’s sideline. At Heinz Field, home of the Pittsburgh Steelers, one of the UNCs is Dr. David H. Jho, a board-certified neurosurgeon, and Director of Neurotrauma and Co-Director of the Concussion Program at AHN.

Kristin Antosz (KA): How are doctors like you selected to work as UNCs at NFL games?

Dr. David JhoDr. David H. Jho (DJ): The AHN Neurosurgery Department selects the individual doctors who work the games, and then the NFL gives final approval. They require that the selected doctors have expertise in neurotrauma and concussions.

The NFL headquarters works with nationally-recognized physician specialists, who help research and make recommendations for local doctors at various sites to be considered to cover NFL games. They turned to AHN’s neurosurgeons to serve as UNCs because of Allegheny General Hospital’s history as a Level-1 Trauma Center and Dr. Jack Wilberger’s previous work in the trauma field. Dr. Wilberger and I work most of the NFL games in Pittsburgh as UNCs, one of us on each sideline.

KA: Was there special UNC training after you were selected or is it more a matter of using your expertise within processes that the NFL defines?

DJ: There are some special training and required protocol items specific to the NFL, but a significant portion of the job involves our own clinical expertise. The UNCs are really part of a team of physicians on the sidelines, and we work closely with the NFL team physicians to try to keep the players as safe as possible.

KA: What does a typical game day look like for you?

DJ: There is a pre-game meeting among all medical staff one hour before each game. I usually go onto the sideline that I am covering after the pregame meeting, check all the required equipment, and then observe the game closely with the team physicians during the game itself. We have two-way communication headsets that connect with the entire medical staff for each sideline and with the ATC Spotters (independent certified Athletic Trainers) in the observation booth.

KA: How do the NFL’s concussion monitoring and diagnosis systems work? Is it just a matter of the UNCs checking players who have been hit or knocked out or are there other considerations?

DJ: There are at least three sets of eyes watching constantly to detect possible concussion injuries for each sideline, including the team physician, UNC, and ATC Spotter. The team physician and UNC observe each play closely from the sidelines; the ATC Spotter in the booth serves as “eyes in the sky” — they can look from multiple camera angles and utilize an injury video review system, which can also be broadcast to a video review monitor on the sidelines.

All of us are not only looking for potential concussion injuries in real time, but also for secondary effects such as players appearing dazed, unsteady, or otherwise unusual. Each NFL team also has multiple physicians of various specialties on its sidelines plus multiple Athletic Trainers, and any staff member has the power to flag a player for evaluation, conveyed by headset communication. Players are also encouraged to self-report or note other players who may be injured, so there are multiple people looking out for concussion-like symptoms.

View from one sideline of football field

KA: Having extra eyes looking for signs of concussions on the field is just one part of the NFL’s official protocol. What else is being done to try to prevent or better treat concussions?

DJ: I believe the most important means for prevention are education and awareness among players, physicians, and the public. Concussions can present in various ways, and it has been increasingly recognized that a player does not necessarily need to be dazed or fully knocked out to have sustained a concussion. Subtle or mild concussions are best recognized by an experienced clinician and by player awareness — those are two very important factors, especially in helping prevent a repeat concussion with second impact syndrome.

Video injury review, helmet technology, and NFL rule changes have all evolved over the years to increasingly emphasize safety. Public awareness has also spread over the years, and the public has become more accepting of rule changes to promote player safety. In addition, the NFL is constantly reviewing and evaluating the system, along with receiving feedback from players and physicians, to continue making improvements every year.

KA: When you’re examining a player, what are the key things you’re looking for to determine whether he’s ok or not?

DJ: One key thing is that we’re observing the player closely during the performance of tests, and not just how he scores on the test items. Even if the player is technically getting the test items correct, the player may still be dazed or foggy or otherwise not quite right, so I typically look directly into the player’s eyes and consider their overall conduct during the test — I look for the player to be sharp, well focused, coordinated, and concentrating appropriately.

Another key thing is the player’s self-reporting of symptoms. Even if the player is performing perfectly on testing, if the player has symptoms, we keep the player out of the game to avoid damage from second impact syndrome. The player is not allowed to return to the same game and will enter a formal return-to-play protocol over time. We have removed players from games who did very well on testing but had persistent symptoms; it really is a combination of reported symptoms and evaluation testing.

KA: These players are so committed to what they do — is it challenging sometimes to convince them to be open about symptoms or that their condition requires further assessment?

DJ: I believe that players have become more willing to be open about symptoms, especially since there has been improved education about the importance of self-reporting symptoms and awareness about the long-term effects of concussions. Players are increasingly mindful of the fact that their actual playing days in the NFL comprise only a part of their early years, with more and more players having second careers in coaching or broadcasting or pursuing other life achievements. Instead of focusing on the short-term importance of individual games, there is more emphasis on long-term health among players so that they can have successful careers after their playing days are over.

KA: When you’re not on the sidelines at Steelers games, you’re a neurosurgeon at Allegheny General Hospital. Do you work much with patients who have concussions there, too?

DJ: I see a variety of patients with neurosurgical problems, which include brain tumors, spine problems, and trauma. Among the trauma patients, I do see a number of concussion patients every week. I am also board-certified in neurosurgery and fellowship-trained in minimally invasive techniques. Not all patients qualify for minimally invasive surgery, so I do a range of standard brain and spine surgeries as well.

KA: What developments in neurosurgery are you particularly excited about?

DJ: I am still fascinated by technology that is not necessarily “new” but has significant impact in the field of neurosurgery. Image-guidance systems (IGS) for brain and spine surgery, for instance, have been invented and refined during my neurosurgical lifetime, which I still find fascinating and highly useful. Even CT scans and MRI imaging and the operating microscope and endoscope have been wonderful developments in neurosurgery. Like GPS or the Internet or cell phones in everyday life, these things are no longer “new” but they have lasting impact.