The NFL's concussion protocol failed Case Keenum. Who do we blame?

The NFL has another ugly concussion situation on its hands. This time it's St. Louis Rams quarterback Case Keenum. He took a hit and banged his head on the ground with one minute left to play in Sunday's 16-13 loss to the Baltimore Ravens. Despite showing the obvious signs of a concussion, as laid out by the league's own concussion protocol, he was allowed to continue playing.

It looked an awful lot like the situation with Colt McCoy in 2011, a situation so egregious and so poorly handled that it prompted the NFL to undertake a major rewrite of the rules governing how players suffering from head injuries are treated. Somehow, through a combination of negligence and ignorance, another player was allowed to stay in the game.

Here's the play, second-and-10 at the Rams' 41-yard line. Timmy Jernigan slips through the Rams offensive line and takes down Keenum for a 10-yard loss. Keenum's head hits the turf, and it's immediately obvious that something is wrong with him. Because of a penalty, there's actually no play there, a detail that will be important later. Watch the hit again.

Here's what the NFL's concussion protocol spells out as the seven observable signs of a concussion, as laid out by the league's Head, Neck and Spine Committee:

• Any loss of consciousness
• Slow to get up following a hit to the head ("hit to the head" may include secondary contact with the playing surface)
• Motor coordination/balance problems (stumbles, trips/falls, slow/labored movement)
• Blank or vacant look
• Disorientation (e.g., unsure of where he is on the field or location of bench)
• Clutching of head after contact
• Visible facial injury in combination with any of the above.

Keenum is clearly displaying four of those signs. He clutches his head immediately after the hit. He tries to get up, but stumbles and goes back down to the turf, and he's still struggling, stumbling even when his teammate tries to help him to his feet. You can't see his face on the broadcast, but it's clear he's punch drunk once he's up, enough that someone should've been able to rattle off this list and get him out of the game, even temporarily to run him through the sideline concussion test.

Once he's up, Keenum ambles toward the sidelines while his teammates on the field stay around for the huddle. He's going over there to talk to Rams head trainer Reggie Scott. The broadcast catches the two talking. Moments later, the game continues and Keenum's there to take a snap.

Let's go upstairs for a moment, because this is where the certified athletic trainer in the booth, the ATC injury spotter, factors into the situation.

The ATC spotter program was implemented in 2012, in the wake of the Colt McCoy hit in the Browns-Steelers game the year before (a hit that looks all too familiar to what happened to Keenum in this game). Until this year, their powers had mostly been limited to communicating with team medical staffs on the sidelines and officials on the field.

If the ATC, who is watching the broadcast feed along with the play on the field, sees something, it's their job to contact an authorized person on the sideline, either the team physician, unaffiliated neurotrauma consultant, or head athletic trainer. The spotter can only tell the team contact about a potential injured player, not make a diagnosis or suggest treatment. They also mark the tape for later review. If action is required, they can send the video of the incident to the appropriate person on sideline, so that the trainer or the team doctor can take the necessary action, like pulling the player from the game.

It's impossible to know what the ATC spotter did at that moment. The Fox broadcast of the game showed a replay of the hit on Keenum while the game was stopped to sort out the penalty. That's when Scott came out to talk to Keenum. Scott might have been alerted to Keenum's injury by the ATC spotter, if the system was working the way it was supposed to.

What about the spotter's authority to stop the game?

In the spring, the league passed a new rule giving the ATC spotter in the booth the authority to stop a game and have a player removed for examination if there is "clear visual evidence" that meets two criteria:

1. A player who displays obvious signs of disorientation or is clearly unstable; and
2. If it becomes apparent that the player is attempting to remain in the game and not be attended to by the club's medical or athletic training staff.

Keenum certainly was injured enough to pass the first one, but once the trainer came out to talk to him, the spotter could not stop the game.

What happens if the spotter doesn't stop the game for an injured player?

Officials can call a timeout for an injured player on the field, or a team can do it, sending out their trainers to deal with the player. Teams are charged an injury timeout, taken from their three timeouts for each half. The injured player must leave the field for at least one down after the timeout is called.

There are several circumstances in which a team would not be charged a timeout inside the two-minute warning, when Keenum was injured, but those did not apply here. The Rams had one timeout left when Keenum went down. They would have lost that had the clock been stopped to deal with Keenum.

Referee Tony Corrente and his crew were busy untangling the confusion around Elvis Dumervil's neutral zone infraction. You can see Corrente making his announcement while Keenum is struggling behind him. However, officials were right there when the hit itself happened, standing barely two feet away while Keenum grabbed his head.

Injury timeouts

The clock was stopped because there was a penalty on the play. That wouldn't have changed the fact that the Rams would have been charged for an injury timeout, according to the rules, whether the Rams or the official stopped play. If the ATC spotter had called for Keenum's removal, the Rams would not have lost a timeout.

There was some speculation that officials and the injury spotter did not bring attention to Keenum's status out of concern for interfering in the game, which was at that point a thrilling 13-13 tie with 1:04 left on the clock, by causing the Rams to lose a timeout or by forcing them to remove their starting quarterback.

Either way, nothing happened. Keenum was dazed but still in the game. Two plays later, Courtney Upshaw comes around left tackle Greg Robinson and brings down Keenum with a strip sack. Keenum never saw him coming. The Ravens get the ball and kick the game-winning field goal on the resulting drive.

Who's at fault?

It's a total system failure. Everybody screwed up, the spotter, the officials and Rams head coach Jeff Fisher.

The spotter in the booth didn't stop the game to call for Keenum to get an examination by the team physician or the independent neurologist. The officials didn't call for a timeout to get an obviously injured Keenum off the field. The Rams went so far as to send their head trainer out to talk to Keenum while the refs were sorting out the penalty on the play, but decided to let him stay in the game. They even had Nick Foles up and throwing on the sideline in the wake of the hit on Keenum. And the nuances of the concussion rules shouldn't have been lost on Fisher either. He's the co-chair of the NFL's competition committee.

After the game, it was reported that Keenum did have a concussion, but nobody thought enough of the obvious observable signs of a concussion he showed immediately after the play to have him removed and go through the sideline examination, per league rules under the concussion protocol.

The NFL will reportedly look into the situation now, according to Ian Rapoport. If the league finds out that someone did violate the policy, the most likely result will be a fine. If the NFL really wants to address the problem with concussions, it's going to need to give its policy some teeth on the accountability side of the ledger if it's going to have a legitimate impact.