Smelling salts and ‘No-Go’ criteria: Why the NFL reviewed Buffalo Bills’ response to quarterback’s head impact

Fourteen million people watched it happen in real time — first the fall, then the brain-rattling impact — and held their collective breath.

They wondered: Was Josh Allen OK? Could he possibly take another snap?

Late in the fourth quarter of an Oct. 6 game between the Buffalo Bills and Houston Texans, Allen, the Bills’ star quarterback, had bolted out of the pocket on third down, and was tackled around his calves by the Texans’ Mario Edwards Jr.

Allen, 28, tumbled sideways. His head slammed so hard against the artificial turf field inside the Texans’ NRG Stadium that it bounced in the air, and his left arm fell limp.

He lay motionless until seconds later, when teammates rolled Allen onto his back, and trainers rushed to his side.

Allen was led into a blue sideline tent, where team medical officials and independent neurotrauma experts are required to follow the NFL’s extensive protocol for concussion evaluation, which includes reviewing video footage and assessing a player’s speech and balance.

Several minutes later, Allen exited the tent, and a Bills employee attempted to hand him smelling salts, which the league has long said are not to be used to revive players from head trauma.

After missing about two and a half minutes of game time — a little more than six minutes total — and with the Bills trailing by three points, Allen returned to the field. (The Bills ultimately lost, 23-20.)

Later, Bills head coach Sean McDermott, a former Philadelphia Eagles defensive coordinator, praised the quarterback for continuing to play after absorbing a “pretty good hit.”

“Josh,” McDermott said, “is a warrior.”

The sequence led to renewed scrutiny of how NFL teams handle players who have sustained potential concussions, at a time when multiple games have been overshadowed by the unnerving specter of players suffering brain injuries.

Independent medical experts have questioned whether the Bills’ medical staff followed the NFL’s evaluation protocol before clearing Allen to return.

Stephen Stache, who was the Eagles’ head team physician in 2018, reviewed footage of Allen’s head striking the field.

“In my opinion, he showed signs of loss of consciousness on the field, which, per the NFL’s protocol, should be a no-go — the athlete should immediately be removed,” Stache, who also works on the Philadelphia Phillies’ medical staff, and as the chief for nonoperative sports medicine at Rothman Orthopaedics, told The Inquirer.

“His limb posturing indicated a loss of conscious neuromuscular control.”

In response to questions earlier in the week from The Inquirer about Allen’s medical screening, the NFL and the players’ union on Friday emailed a joint statement, which read:

“The NFL and NFLPA have reviewed the reports from the Unaffiliated Neurotrauma Consultant and Booth Spotters and those reports confirm that the steps required by the concussion protocol were followed in the evaluation and clearance of Bills’ quarterback Josh Allen in last Sunday’s game.”

Neither party believed that Allen lost consciousness.

After a team practice Wednesday, Allen was asked about his swift return to the field.

“I obviously went into the tent,” he told reporters. “I can only control what I can control. What we talked about there, they deemed me cleared to play, and that’s what happened. That’s as deep as I’ll get into it.”

Allen is expected to play in the Bills’ Monday Night Football game against the New York Jets.

Chris Nowinski, a neuroscientist and the cofounder of the Concussion Legacy Foundation, which advocates for athletes and military veterans who have suffered brain injuries, had called on the NFL to investigate the Bills’ evaluation of Allen.

“It’s just a reminder that the NFL has changed on paper,” Nowinski said. “I believe that the current NFL leadership is trying to make the game safer. But there’s a gigantic gap between what the NFL says should happen, and what happens on the field, when everyone is fighting for their job.”

The NFL’s protocol for diagnosing concussions runs 19 pages, a measure of how much its approach has evolved since the 1990s, when top league officials actively dismissed concerns about players sustaining brain injuries.

Now, athletic trainers and independent neurotrauma consultants look from observation booths for signs of concussive impacts, and each team is assigned independent consultants to evaluate players alongside the team’s medical staff.

“I do think they have an excellent protocol,” Stache said. “But obviously, errors still happen.”

According to the protocol, a player must be “removed immediately” if he exhibits certain “No-Go” symptoms: losing consciousness; amnesia; confusion; and ataxia, which includes balance and speech abnormalities.

During Stache’s time with the Eagles, he participated in blue sideline tent evaluations.

Players are shielded from view, but still surrounded by thousands of screaming fans and the usual cacophony of stadium noise — bellowing public address announcers, thumping music, teammates and opponents crashing into one another on the field.

“It’s a particularly stressful evaluation,” Stache said. “But I do think, for how the protocol is established, it does allow you to gather some degree of information.”

In addition to possible “No-Go” symptoms, players’ gait, eye movement and cervical spines are examined in the tent, and video footage of the play during which they were injured is supposed to be reviewed.

“If any elements of the sideline assessment are positive, inconclusive, or suspicious for the presence of a concussion,” the protocol reads, “the player must be escorted to the locker room immediately for the complete NFL Locker Room Comprehensive Concussion Assessment.”

The final responsibility for returning a player to the field rests with each team’s physician, according to the protocol.

Stache noted that in some instances, an abrupt impact — like Allen’s head bouncing off the turf — can cause whiplash, followed by a secondary coup-contrecoup injury, which occurs when the brain strikes one of the sides of skull, then the other.

“There’s a wide array of forces,” he said, “that can lead to a concussion.”

Allen initially told reporters that he was evaluated in the tent for an ankle injury, in addition to a possible concussion.

Nowinski questioned how the quarterback could have been thoroughly screened for both ailments in just a handful of minutes.

“In the big picture, this has never been about solving concussions,” he said. “It’s been about being more ethical about concussions. That’s why the Allen situation is very concerning. There are some questionable choices being made in the medical care for a vulnerable person who may have been unconscious.”

Stache and Nowinski were each troubled by the sight of a Bills staffer trying to hand Allen smelling salts.

“Allen appropriately passed up the smelling salts,” Stache said, “but the optics on that were very bad.”

For decades, NFL trainers used the ammonia inhalants to help revive players who sustained concussions, a custom that members of the 1980 Eagles recalled as part of a recent Inquirer investigation, The Final Penalty.

Players still widely use the inhalants as a temporary adrenaline boost. In 2017, though, the NFL told ESPN that smelling salts aren’t used in “any way” for treating concussions.

» READ MORE: The Final Penalty: How dementia-striken ex-Eagles fought to be compensated by the NFL's controversial concussion deal

The Allen controversy erupted just days after the NFL announced that teams had reported 44 concussions during the preseason, down from 58 in 2023, and the lowest total since 2015, when it first began tracking preseason brain injuries. The league cited wider use of protective Guardian Caps and kickoff rule changes as part of its ongoing efforts to reduce concussions.

Nowinski said the lower preseason figures are a positive development.

“But it might also be that players are scared to death to report concussions, because they’re scared to be cut,” he said. “The number of reported concussions is not even in the ballpark of actual concussions.”

Concern about the long-term health risks of repeated head injuries has continued to loom over the league.

During a September Thursday Night Football game, Miami Dolphins quarterback Tua Tagovailoa suffered the fourth concussion of his career, after he collided with Bills safety Damar Hamlin.

Tagovailoa’s hands jutted out in a fencing response, which is sometimes observed in victims of traumatic brain injuries, and was removed from the game. The Dolphins later placed the quarterback on injured reserve.

That same month, a Harvard University Football Players Health Study, published in the medical journal JAMA Neurology, found that 34% of nearly 2,000 former NFL players felt certain that they had the degenerative brain disease Chronic Traumatic Encephalopathy, which can be diagnosed only after a person has died.

And the Eagles lost two of their stars, wide receiver DeVonta Smith and right tackle Lane Johnson, to concussions each suffered during a Sept. 22 victory over the New Orleans Saints.

Both are expected to return Sunday for the team’s game against the Cleveland Browns.

“It’s just a violent game,” Stache said. “There’s a substantial, inherent risk of direct blows to the head.”