Alvaro Pereira, one of the stars of Uruguay's national team, was unconscious. It didn't take a trained medical professional to see that he had taken a blow to the head, fallen to the turf and then took at least 15 seconds before he showed any signs of consciousness.
It was clear to everyone—the players, the referee, the TV commentators—that Pereira was unconscious. At this stage, there's no further diagnosis necessary.
It seemed Pereira had suffered, by FIFA's own standards, a concussion and should have immediately been taken out of the game against England and examined, then placed under the return to play (RTP) regulations that are in place for the players' safety.
Instead, Pereira hopped off the stretcher and back into the game, waving his finger at his own doctor. He completed the game and had no further apparent issues, but he never should have been back out on the field.
It should be noted that, as yet, Pereira was never officially diagnosed with a concussion despite meeting every condition of FIFA's own concussion policy.
This is where the failure occurred. Pereira should not have been allowed back on the pitch at his own discretion, but it's hard to blame a competitor for wanting to play in such a big match. However, he should not be allowed to make this decision, let alone at a time where his brain may be injured.
Yet no one stepped in—not the coach, not the doctor and not even FIFA's independent doctor on the sideline. FIFA's doctor did not even examine Pereira until after the match, at which time Pereira was diagnosed as concussion-free.
The problem is less about the letter of FIFA's concussion protocol and more about the enforcement of it. FIFA's policy starts with "recognize and remove," but Pereira's case highlights that even in the clearest of situations, that's not always followed.
For the remaining game time after running back out on the pitch, Pereira was at significant risk of further injury, and not just to his head, though a second concussion or even a jarring from a hard header could have exacerbated the brain injury.
A player in the immediate aftermath of a concussion will have slower reaction times, and some studies suggest that there is a connection in the NFL between concussions and knee injuries.
Nor is this the first situation like this. While Pereira's situation was very visible because it took place in the World Cup, a similar situation took place last season in the English Premier League.
Again, a policy and the presence of qualified physios and doctors did not prevent Lukaku from returning to the game. While we cannot know what they saw during any cursory examination, it's clear that the time constraints and pressure of playing a man down is problematic for the proper management of a brain injury.
The MLS made a step forward, adopting new changes to their already stringent concussion management protocols earlier in June. The league will use a cloud-based app called Integrated Concussion Evaluation (ICE), the same already in use by the NFL, to help diagnose concussions. While it is often called a sideline test, the player should actually be taken off the field and into a quiet location for the testing.
In the NFL and MLS, players are examined on the sidelines first and then taken for the ICE testing. This has been an issue, with some players being returned despite clear signs of concussion that can be easily seen, such as unconsciousness or wobbliness in walking.
This matches or exceeds other policies in sports. The NFL has taken a lot of heat for its slow response to a problem that is more serious than it is for other sports due to the nature of the game and hard contact, but they now have independent observers and a sideline testing program.
While concussions have not been reduced by the new changes, it's a positive step for management and possible long-term consequences.
MLB, the NBA, the Olympics (and their associated sports) and all other organizations that I could find also have concussion policies in place. They are largely based on the best practices and recommendations of doctors like Dr. Robert Cantu, whose work on concussions and concussion management is longstanding.
Baseline testing, protocols for sideline testing and RTP regulations are relatively standard, though adjusted for each sport.
However, the best policies and intentions are thrown by the wayside if a player is allowed to wave his finger and run back onto the field. FIFA's policy on its own should be enough, but it is clear that the execution of that policy is problematic. The game should never be allowed to take precedence over a player's health, at any level.
It's not that these injuries are difficult to see. While diagnosis will always take a trained professional on the sideline, at least the question to have someone checked could be asked easily. During Sunday's match between Belgium and Russia, one of my Twitter followers, Alex Johnson, thought he saw some issues:
@injuryexpert they didn't show a single potential injury in the highlight package for Russia v Belgium. I counted 3 possible concussions— Alex Johnson (@alexriejohnson) June 22, 2014
I only saw one situation during that game where I hoped for a sideline check, but a trained "eye in the sky" could hopefully do better on targeting the situations that called for a more in-depth check.
FIFPro, the worldwide players' union, has suggested a simple solution: allowing teams to use a "concussion substitution."
When the independent doctor on the sidelines determines that a player has been brought off for a concussion check, a substitute could come on for that player for the duration of the exam. If the player is cleared, he can return to the game. It would not count against the normal three substitutions.
With flopping rampant in the game, it needs to be clear that a team could not make this substitution. It would only be called for by the independent doctor, with the team only selecting the substitute. By making this call independent of the team or even the player, there should be very little room for abuse.
It's also likely that, at least at the youth levels, technology will come into play. Several companies are working on devices that either protect the head or measure the forces on the head.
While it would be difficult to mandate this kind of device for players at any level, sensors are becoming a more significant part of sports. If a company like Unequal can come up with a headband that not only reduces forces but passes the mirror test, some players would wear it. We're not talking about a full Petr Cech headgear!
Dr. Boris Gojanovic, the head of the Swiss Olympic Center's sports medicine department, makes it clear in this strongly worded article that the policy itself is not the problem. Instead, Pereira himself is quoted as saying that because Uruguay won the match, his situation was worthwhile. For too many players and coaches, the result trumps their own health.
The doctors and physios are there for a reason, and FIFA needs to act quickly to make sure that situations like this are no longer decided by non-medical staff. The next time a player tries to wave off the doctor, the doctor should point to the sideline.