On Saturday, October 14th, in a heated Red River Rivalry, millions watched the University of Texas quarterback, Sam Ehlinger, get pushed out of the pocket and take off on a run with 5:20 left in the game. As he reached the sideline, Kenneth Murray of the University of Oklahoma tackled Ehlinger out of bounds. As he fell to the ground, his head hit the turf. Almost immediately, medical personnel surrounded him.
The footage (see below) appears to show that Ehlinger’s eyes are closed as he lay motionless in an awkward position for around 6 seconds. Ehlinger’s eyes open while the medical personnel are kneeling over him. This behavior suggests that Ehlinger experienced a brief loss of consciousness. This is significant. Any loss of consciousness, regardless of how long, is a red flag when it comes to suspecting a concussion, even if other symptoms aren’t immediately apparent.
What happens next has left us confused and concerned. Once Ehlinger is on his feet, he disappears into the medical tent on the sideline. Approximately 2.5 minutes later, he is back on the sideline with his teammates. And, just 5 plays after he hit his head, he returned to the game. Millions of fans watched as this unfolded on national television. Many of us were in disbelief.
The Texas quarterback returns to the game and his level of play is noticeably different. He makes a couple of runs, but struggles to complete routine passes and fumbles a snap. As the clock winds down and his team faced 4th and 13, Ehlinger has the game in his hands when he makes an uncharacteristically odd decision. He scrambles out of the pocket and throws the ball away. This decision cost Texas the game. It’s not about the result, but it’s a clear example of how playing through a possible concussion doesn’t only affect the individual, it can affect the entire team. Additionally, that type of behavior led us to wonder if Ehlinger was thinking clearly. Could it be that his cognition was altered from the hit he took?
As Oklahoma came away with the victory, many in the media praised Ehlinger’s “gutsy” performance. Despite the fact that he possibly suffered a concussion, he returned to play and finished the game. In stark contrast, social media became ablaze with criticism of Texas and the fact that Ehlinger was allowed to return to the game. Due to the likely loss of consciousness, many expressed their belief that he suffered a concussion. Others acknowledged that he lost consciousness, but weren’t convinced it was concerning for a concussion.
During the post-game press conference, Ehlinger was asked about the hit he took and his quick return to play,
“I wasn’t ever confused where I was at all,” Ehlinger said after the game. “It was a hard hit. My head hit the ground pretty hard. And they were just taking precaution. I told them immediately I could go back in. I felt fine. They just took me into the tent to make sure everything was okay, go through the protocol and send me back out there.”
We have a few concerns about Ehlinger’s comments. First, his statement adds to the misconception that one symptom, such as confusion, can determine the presence of a concussion. In reality, there are numerous variables that must be assessed when a concussion is suspected. One example comes from the CDC, who provides a list of 27 symptoms to evaluate for a concussion. These symptoms are broken into 4 categories: observable, physical, cognitive, and emotional. “Loss of consciousness,” even if it is brief, falls under the observed category.
Second, the fact that Ehlinger went “through the protocol” and was only out of the game for mere minutes sparked speculation about what exactly the protocol entailed. Here is why, if we focus on just one aspect of a sideline assessment, the cognitive domain, it leads us to the 2016 Consensus Statement on Concussion in Sports. According the consensus of concussion experts, “Sideline evaluation of cognitive function is an essential component in the assessment of this injury[concussion].” The SCAT5
and Standardized Assessment of Concussion (SAC) are provided as examples of cognitive assessments. Both of these assessments require a minimum of 10 minutes to complete and can take upwards of 20 minutes. Although Ehlinger stated he was asked to complete serial 7’s, this is a far cry from a comprehensive cognitive assessment. Based on the length of time Ehlinger was in the tent and his account of the protocol, it’s safe to say that an adequate assessment of his cognition did not take place.
SyncThink, the manufacturer of EYE-SYNC, describes it as “60 seconds to objective, data driven clinical decisions.” Through the use of a pair of goggles, the athlete’s eye movements are tracked for 60 seconds. In an oversimplified explanation, the product measures how well the eyes are working together, and the presence of an ocular-motor issue can be detected. This ocular-motor function is used to determine whether or not a concussion has occurred. While this tool appears promising for detecting concussions, we are concerned that it may be the only tool used in a sideline assessment, especially given its brevity. Perhaps this is what happened with Ehlinger.
Our caution appears to be shared even by SyncThink as their website states, “Based on the latest research that ocular-motor and vestibular-balance impairments account for most neurological dysfunction, the protocol first assesses for those impairments. In so doing, the potential risk of further injury is decreased.” The key here is that they acknowledge most, not all, neurological dysfunction can be detected and the potential risk is decreased, not eliminated. Therefore, other assessments must be used in a sideline evaluation.
We want to be clear, EYE-SYNC has over fifteen years of research and we are not questioning the validity or the research that supports its use for concussion detection. In fact, we were not concerned at the use of this technology at all until Ehlinger’s brief assessment sparked our curiosity. At that point it was brought to our attention that EYE-SYNC has been accused of promoting their product as an “advanced cognitive assessment.” A claim that was not included in the FDA approval.
— Kent Johnson (@37919KJ) October 18, 2017
Upon further research, we discovered a letter from the FDA to SyncThink dated July 31, 2017. In this letter, the FDA warned the company to remove its claim that EYE-SYNC is an “advanced cognitive assessment.” It is unclear if this warning impacted the manner in which EYE-SYNC has been marketed, but the time frame of this letter suggests that colleges and universities had already signed on for the use of EYE-SYNC in their protocol. To read the full letter, click here.
The pressure to diagnose and assess a concussion as quickly as possible during a competitive event is understandable, but the problem is that it’s usually not possible for a concussion to be easily or immediately detected. In fact, we know that symptoms can have a delayed onset. Ehlinger appears to suffer loss of consciousness in the game against Oklahoma, and, while we are pleased that he was assessed, it is perplexing why he was allowed to return to play in less than 5 plays. It’s even more concerning that he was allowed to remain in the game when he was exhibiting atypical decision making.
Ironically, the protocol provided by the University of Texas on the NCAA website defines a concussion as, “a change in brain function; following a force to the head, which; may be accompanied by temporary loss of consciousness.” This does not say a temporary loss of consciousness may be accompanied by a concussion, which suggests that a loss of consciousness is indicative of a concussion. So, even if Ehlinger passed the sidelines assessment, shouldn’t the loss of consciousness be an automatic removal from play or at least require a more lengthy evaluation?
The UT Athletics Department’s protocol also states that a “sideline assessment will be performed at the time the injury. The components of the sideline evaluation include assessment of symptoms, cognition, oculomotor function, and balance.”
Given that the UT Athletics Department calls for a cognitive assessment as part of their sideline evaluation protocol and that we know cognitive assessments take a minimum of 10 minutes, the fact that Ehlinger was in the medical tent for only 2.5 minutes means it’s safe to say that this part of the protocol simply didn’t take place. While the only people who know what assessments were administered were in the medical tent at the time, logic supports that the UT medical staff violated their own concussion protocol.
From the moment Ehlinger hit the turf on October 14th and re-entered the game 5 plays later, we have remained concerned for his health. We know all too well the toll that an undiagnosed or mismanaged concussion can have on an athlete. Research shows that if the brain is not fully healed from the first concussion and an athlete suffers a second concussion, recovery may become more complicated and symptoms often take longer to resolve. This is why it’s important to always err on the side of caution when dealing with a suspected concussion. There was no reason why a thorough evaluation couldn’t have taken place. Our college athletes deserve better and Sam Ehlinger deserved better.
We wish that we could say that despite that hit in the Oklahoma game, Ehlinger is doing well. Unfortunately, he took a similar hit the next week against Oklahoma State on Oct. 21st. He was tackled while being rushed out of the pocket. Once again his head hit the turf, but he didn’t miss a play. However, he did show similar difficulty with his decision making which culminated in throwing an unusual interception to end overtime in a loss.
After two head impacts to the ground and two lost games, this week, less than 24 hours after suffering another hit to the head, it was announced that Ehlinger missed practice on Sunday, October 22nd and entered concussion protocol. As UT prepares to take on Baylor on Saturday, they will have to do so without the leadership of Ehlinger. Could this have been prevented by him being removed from the Oklahoma game? It’s difficult to say, but we can’t help but wonder what impact that decision had on his current health. We wish Ehlinger a full and swift recovery.
While our sport culture has come quite a way in a short amount of time with our understanding and response to concussion, the handling of this incident exposes how much growth we still have to do. Although nothing can be changed about the past, hopefully this series of events serves as a reminder of the importance of a thorough sideline assessment. One that includes multiple measures in the proper environment.
Finally, even though we understand Ehlinger’s desire to get back in the game, we urge athletes to remember, if you get hit, sit for a bit!