When New England Patriots tight end Rob Gronkowski got up after being hit helmet-to-helmet last week by Jacksonville Jaguars safety Barry Church, it was obvious to TV viewers that Gronkowski wasn’t right and might have suffered a concussion.

It’s not always that obvious.

“It’s hard,” said Sue Stanley-Green, an associate professor and program director of athletic training at Florida Southern. “It’s not an easy call. There are times people are slow getting up. At Kentucky, we knew the players who were going to take their time getting up. They weren’t hurt. They were just lazy, tired, whatever.”

Stanley-Green’s experience at the University of Kentucky, where she was a football trainer for 15 years, made her an ideal candidate for the NFL’s ATC Spotter Program. ATC stands for athletic trainer certified. She just completed her second year as a spotter for the Jaguars and is working today's Pro Bowl in Orlando.

The impetus to add spotters, who are independent, certified athletic trainers, came late in the 2011 season. Cleveland Browns quarterback Colt McCoy received a helmet-to-helmet hit from Pittsburgh Steelers linebacker James Harrison. It was apparent to the TV announcers and viewers that McCoy was shaken up.

“When he came off the field, he said his hand hurt,” said Dr. Robert Cantu, who is co-founder of the CTE Center at Boston University and co-founder and medical director of the Concussion Legacy. “The trainers checked his hand. No one checked his head.”

The Browns’ trainers did not see the hit because they were tending to other players. McCoy was diagnosed with a concussion after the game.

As a result of the incident, the NFL and the NFL Players Association came up with a program to reduce or eliminate similar situations, and the idea to put spotters in the booth emerged.

There are stringent requirements to become an ATC spotter. Trainers must meet the following criteria:

• Maintain current certification by the National Athletic Trainers Association Board of Certification.

• Have an undergraduate degree from a four-year program.

• Have a minimum of 10 years' experience as a certified athletic trainer.

• Have major college or professional sports experience.

• Never have been employed as a head athletic trainer by an NFL team.

• Have not been employed by an NFL team in the past 20 years.

In addition to working with Kentucky football, Stanley-Green has worked high school football and arena league football.

“I’m kind of known as the football girl,” she said. “They had a hard time finding anyone in the Jacksonville area that met the criteria, so they asked me to put my name in to apply.”

Eyes in the sky

In her two years as an ATC spotter, she has seen the improvements to the program. When the spotters first appeared in the booths in 2012, there was just one. Now each team has three, and there are two in the booth each game.

When she went to Dallas for training prior to her first year, the spotters were put with game-day operations people, the officials, chain crew, etc.

Last summer in New York, the training was with the medical staff, trainers, team physicians, independent neurologists.

“That made a world of difference,” she said, “just everybody working together, feeling like you’re part of the medical staff rather than feeling like you’re part of the guys who hold the chains. We all felt a big difference. The value of what we’re doing was a lot different. And the communication was much better.”

The spotters' role is to be the eyes in the sky. They watch each play and identify players who might be injured. They concentrate on concussions, but they’ll look for other injuries, too.

In the booth, each spotter has monitors and their own video technician, a change when initially there was just one video technician.

The spotters wear headphones. They have the broadcast feed in one ear so they hear what the public is hearing. In the other ear, they have access to each team’s medical staff. One spotter will listen to the home team, and the other will listen to the visiting team.

The spotters also have access to the video monitors that are on the field, and most importantly they have direct access to the head official.

There are phones to both sidelines, and they have a radios that allow them to contact the instant-replay guy and have him get the head official on the radio as a last resort.

“We’ve got wires coming everywhere,” Stanley-Green said. “You’re hearing one thing in one ear and one thing in the other ear, and you’re watching the monitors.”

Stanley-Green said she’ll watch the live action on the field, then watch the play again on the monitor, which she has set with a three-second delay.

“When you work as an athletic trainer, you get to watch the game a certain way,” she said. “You know how it unfolds. You know the injuries happen here first, then you go to the backfield and then you go downfield. Then you know where the collisions occur on kickoffs and punts. So you’re very used to watching the game unfold for injuries. You train yourself.  ... That part is easy.”

Mastering the technology, she said, was the hard part.

“The first thing was, oh my God, I hope I’m talking to the right person,” Stanley-Green said. “It wasn’t the job. It was never about doing the job. It was like riding a bike. I’ve watched football for so many years, I know how to do that. I’m good at doing that. I was like, holy moly, I hope I’m talking to the right person. Honestly, that was the most complicated part.”

The protocol

If the spotters see a player take a helmet-to-helmet hit and get up slow, or if they see some other kind of hit where a head injury can occur, they’ll call down to the sideline.

“If we call down, they have to check them,” she said. “If they don’t, it’s a pretty big fine. But they’ve got to put them into a concussion protocol.”

The concussion protocol begins with a player being removed the game and evaluated on the sideline. There is a checklist of tests that are performed. If the player passes, he can return to the game. If he fails any part of the test or it’s inconclusive, the player is taken to the locker room for additional tests.

“It’s very extensive,” she said. “Much more based on science as far as all the different symptoms you see. It’s balance, it’s cognition, it’s memory, headaches and all different kinds of symptoms. So you go through that, and it’s a very extensive process, much harder, not impossible, but much harder to fake your way through.”

And she acknowledged that there are times that the symptoms don’t show up until later. She said players have had “many, many years practicing lying about their injuries. They’re very good at it. They know what to say. They know what not to say.”

If at any time, the player loses consciousness or exhibits confusion or amnesia, he cannot return to the game.

It’s not a perfect system. For instance, the spotters just have access to the broadcast feed. Stanley-Green said the NFL is working to give them access to all the cameras. She noted that one hit might look vicious on one camera view, while another camera angle shows the players barely glanced each other.

It’s all part of getting as many eyes on the play as possible.

“I think that the NFL is trying very, very hard to get it right,” Cantu said. “The spotter is another set of eyes to look for signs of concussion.”

Room for improvement

Chris Nowinski, co-founder and CEO of the Concussion Legacy Foundation, said that while the NFL is doing a good job with the concussion protocol in the locker room, there’s room for improvement in the sideline examinations, specifically because symptoms don’t show up.

“That’s a big part of the problem itself,” he said. “They have a quick examination and are put right back in the game.”

Nowinski said adopting the King-Devick Test, which is endorsed by the Mayo Clinic and is used by the Canadian Football League, would be more effective than the current tests the NFL uses on the sideline. The King-Devick Test measures rapid-eye movement. The player is asked to read numbers on a line, and his time will be slower than his baseline test when there’s a concussion or brain injury.

Stanley-Green said the King-Devick Test is a good test but doesn't test everything. She added that aspects of the test are incorporated into the sideline test.

Still, Nowinski agrees with Cantu that the NFL is trying to get things right.

“There’s no doubt it keeps getting better,” he said.

Jim Mackie, one of the Jaguars’ spotters who works with Stanley-Green, has been a spotter for three years.

“The NFL has been very open to suggestions and very approachable,” he said. “They willing to make any changes.”

The addition of having two people in the booth, he said, has been very important.

“There have been times where we have a situation where we have to look at video,” he said. “With two people, one of us can look at the video, and that allows the other to keep an eye on the game.”

Not every call to the sideline is to have a player taken out of the game.

If it looks like a player took a hard hit, they’ll call down to the sideline and tell the medical staff they have the video of the play pulled up in case they want to look at it.

Sometimes the medical staff on the sidelines will call up to have the spotters look up a play.

“There was one instance on the visitors' side that a player self-reported,” Stanley-Green said. “So they were asked to go back and look at the video. We went back through the video to find something, and the hit was probably off camera. So we didn’t have the view to show them.”

That is another instance in which having access to more cameras will be beneficial.

It’s all about having more eyes on the lookout for potential issues. Even the officials receive training on what to look for when players might be injured, which was evident in the Gronkowski hit.

“Here’s an example of a player getting hit and the officials notice he was showing signs of a concussion,” Cantu said.

Gronkowski was diagnosed with a concussion and was listed on the Patriots' injury report. His status for the Super Bowl remained uncertain Friday.

Every time a call is made to the sideline, or if the sideline calls up, the video is tagged and documented. There is an extensive report the spotters must give to the NFL after each game. Every tagged injury must include the player’s name and number, the injury, how it happened and whether the player went back on the field, along with other details.

Trying to make it safer

At the end of the day, Stanley-Green feels confident in the calls she’s made. There’s follow up on both sides because she said you want to know you made the right call.

The work is intense, and Stanley-Green said she’s exhausted after every game. It’s like she’s watched four or five games, she said, because she watches every play multiple times looking for injuries.

Still, she’s enjoyed doing it and said it’s been fun.

“I’m still the football girl,” she said. “I still truly love the sport, but I’m also very passionate about trying to make it safer. I think that’s why it’s important that I enjoy doing the spotter thing because I feel like I’m part of trying to help make the game safer.”

Roy Fuoco can be reached at roy.fuoco@theledger.com or at 863-802-7526. Follow him on Twitter: @RoyFuoco.