What actually happens when an NFL player enters concussion protocol?

BUFFALO, N.Y. (WKBW) — Football is "America's Game", and millions of fans across the country know the sport inside and out.

Many are also familiar with the potentially career-ending and life-threatening injuries that can plague NFL players, concussions most notably.

The NFL concussion protocol, implemented in 2011, is a set of actions and decisions that determine if a player is currently suffering from a concussion. If concussion symptoms are spotted, players are escorted off the field in order to undergo an examination and evaluation.

With millions watching the Thursday night NFL matchup between the Miami Dolphins and Cincinnati Bengals, questions regarding the NFL's concussion protocol have arisen. Questions that also concern who exactly is in charge of deciding if a player is ready to return to the field after suffering a major hit on the field. And what happens when the wrong decision is made?

In Thursday night's game, Dolphins starting quarterback Tua Tagovailoa suffered a hit to the back of the head and neck after being sacked by Bengals nose tackle Josh Tupou.

Tagovailoa immediately showed signs of "fencing," a reaction where the arms are held in the air in the seconds after an impact to the head or neck.

After being stretchered off the field and taken to a local Cincinnati hospital, it was announced that the quarterback was conscious and was not suffering from any structural damage.

Tagovailoa remains in concussion protocol.

However, the week before the Thursday night game, Tagovailoa suffered a head injury after hitting the ground during the first half of a home game against the Buffalo Bills.

Tagovailoa was slow to get up and was later taken to the locker room.

The quarterback returned to the game after he was initially marked as questionable to return.

The NFL's Player Association requested a review of the concussion protocols after Tagovailoa's quick and possibly questionable return to the game.

According to the NFL's Concussion Game Day Checklist, the following actions are supposed to determine whether or not a player has suffered a concussion and is in the right condition to return to the field.

What happens when a player receives a blow or impact to the head during a game?

• When a player receives a blow or impact to the head and shows symptoms related to a concussion, the player is supposed to be immediately removed to the sideline or stabilized onfield, if needed.
  • Even if a blow to the head does not occur, an (ATC) athletic trainer spotter, booth ATC, team physician, NFL official, coach, teammate, or UNC (Unaffiliated Neurotrauma Consultant) can initiate concussion protocol.

• A survey is then performed where the player's helmet is removed. The team's physician and a UNC conduct the survey.
  • The player may return to the field if the survey is normal: the player has a recollection of the event, passes Maddock's questions, and a video review is "benign."
  • A focused neurological exam is also performed
    • A cervical spine exam, an evaluation of speech, observation of gait, eye movements, and pupillary exam are also performed.
  • The player may not return to the field if the player has loss of consciousness, gross motor instability, confusion, or amnesia.
• What are Maddock's questions?
  1. At which field are we?
  2. Which quarter is it?
  3. How far into the quarter is it - the first, middle, or last 10 minutes?
  4. Which side scored last?
  5. Which team did we play last week?
  6. Did we win last week?
• What happens after a player fails the sideline survey?
  • After a failed sideline survey, the player is taken to the locker room where an exam is performed. If the exam is normal, the player may return to the field.
  • The exam consists of a complete NFL SCAT (Standardized Concussion Assessment Tool), a tool used to evaluate concussions by healthcare professionals. The exam also consists of a complete neurological exam.
• Steps after a failed locker room exam?
  • The player stays in the locker room and undergoes periodic evaluation by a medical team
  • A follow-up neurological exam is performed.

What happens when a team fails to properly follow concussion protocol?

• In 2016, The NFL and NFLPA announced a new policy to enforce the above concussion protocol. The new policy implements a "strict and fair" process that investigates incidents regarding concussion protocol and what discipline will be enacted.
  • A first violation by a team will require team employees or medical team employees to attend a remedial education and/or the team will pay a maximum fine of $150,000.
  • A second violation will result in a minimum fine of $100,000 against the team.
  • If it is agreed that a violation involved aggravating circumstances, the team will be subject to a fine of no less than $50,000.
  • If the NFL Commissioner determines that a medical team failed to follow the protocol in order to win a game, the Commissioner can require the team to forfeit draft picks and impose fines that can exceed the amounts above.

This story was originally reported by Imani Clement on wkbw.com.