Coaching: Hazardous to your health?

— -- When his lungs tightened, his head clouded and his knees buckled, Denver Broncos head coach John Fox slowly crumbled to the ground on a North Carolina golf course. Gasping for air, he closed his eyes and prayed in ways he'd never had to before in his 58 years of life. God, you get me out of this, and I'll get it fixed right now, Fox thought as fearful friends called for medical help. It was the kind of moment that can make any man rethink every single way he approaches his life.

It's been nearly six weeks since Fox underwent aortic heart valve replacement surgery to repair the condition that threatened him that afternoon, a genetic defect that has been with him since birth. Fox will be the first to say that coaching football had little to do with this medical problem, that it could've occurred if he taught Pilates for a living. What he can't deny is that it has forced him to be even more grateful for the blessings in his life. His situation also reminded coaches across the NFL how important it is to appropriately handle the intense pressure that comes with their jobs.

Those men took notice when Fox's heart issue sidelined him for more than a month. They paid equal attention when former Houston Texans head coach Gary Kubiak – who was fired last Friday – sustained a mini-stroke during a 27-24 loss to Indianapolis on Nov. 3 and had to be rushed to the hospital that night. "I'm sitting there watching that Sunday night game, and I'm thinking [I'm about to have] heart surgery and now Gary is going down with a stroke," Fox said. "That was a scary sight."

Every head coach in the NFL had to be thinking similar thoughts. Being one of the 32 men who hold such jobs means having a unique and sometimes unhealthy set of talents. They have to be sufficiently driven to work excessively long hours, insanely focused to tune out relentless scrutiny, supremely confident to handle the reality that some might only last two or three years on the job and diligent enough to keep grinding when the average person would surrender to fatigue. For some head coaches, sleeping at the office is a badge of honor.

The culture of football has glorified such men for round-the-clock commitment to their craft for decades, with George Allen, Marty Schottenheimer and more recently Jon Gruden setting the standard for workaholic coaches. But we've also seen the price that comes with that uncompromising approach. Thirty years ago, Dick Vermeil resigned from his job as the  Philadelphia Eagles' head coach because he felt physically and emotionally fried. Jimmy Johnson also cited burnout when he quit the Miami Dolphins after the 1999 season, as did Bobby Ross when he left the Detroit Lions midway through the 2000 campaign.

Other coaches have suffered tragic personal losses during their NFL tenures. Former Indianapolis Colts coach Tony Dungy, one of the most grounded and spiritual coaches anywhere, lost his 18-year-old son James to suicide late in the 2005 season. While coaching in Philadelphia, current Kansas City Chiefs head coach Andy Reid watched his two oldest sons – Garrett and Britt – struggle with drug use and arrests in 2007. Garrett eventually died of a heroin overdose in Aug. 2012.

Though some people thought Reid might take a break from coaching after such a devastating loss and being fired by the Eagles, he jumped at the chance to continue coaching in Kansas City this year. "When you see what Tony and Andy have gone through, it hits home," said Cincinnati Bengals head coach Marvin Lewis. "I was lucky enough to work with two head coaches – Bill Cowher and Brian Billick – who had young kids when they were in the situation I am now. They really believed it was important to take time and spend it with family and to encourage their [assistant] coaches to do that as well. I spent a year with Steve Spurrier [in Washington in 2002] and I saw how much family mattered to him. You can't lose sight of that stuff."

"The workload will take its toll on you during the course of the year," added St. Louis Rams head coach Jeff Fisher. "You are staying up late, you're traveling and it's one week after the next, so you've got to take care of yourself. I don't think anybody takes better care of himself than Gary Kubiak, from what I know. ... We all have that responsibility."

That is something that remains easier said than done. Baltimore Ravens head coach John Harbaugh recently shared his typical in-season week with ESPN The Magazine. He spent so many hours meeting, breaking down film and preparing for an opponent that the story read like the life of a four-star general bracing for combat. Harbaugh also told The Magazine, "I don't believe in diminishing returns in this job. To me, that doesn't apply. I think every minute matters. Every week, there's more you could do."

Fox used similar blinders when addressing his heart ailment. Though doctors had suggested he undergo surgery to treat it this past summer, he opted instead to postpone it until after the season. The Broncos had been the top-seeded team in last season's playoffs before the Ravens upset them in the divisional round, and they are widely expected to make strong run at Super Bowl XLVIII. Fox couldn't see the logic of letting such a rare opportunity pass him by when there was plenty of offseason time to heal.

Fox – who coached his first game since surgery last Sunday against the Tennessee Titans – admitted that he'd probably make a different decision if presented with that same option today. "I knew things were deteriorating in June," Fox said. "But I also knew we had a good team. … That turned out to be an unhealthy move. If I hadn't gotten this [surgery] done when we did, I would've been looking at open-heart surgery."

Fox's willingness to press forward, even in the face of serious medical news, isn't surprising. Most NFL head coaches struggle with conceding to limitations, mainly because there is so much they want to accomplish. "It's always been a demanding job," said Marv Levy, who spent 17 years as an NFL head coach, the last 12 with the Buffalo Bills. "I remember being an assistant with the Washington Redskins and asking [quarterback] Billy Kilmer if he ever wanted to be a coach. He said, 'No way. I don't want to spend 15 hours a day in a 10-by-13 cell.'"

"The one thing that is constant for every coach is that you're always fighting against time," said ESPN analyst Herm Edwards, who served as head coach for both the New York Jets and Kansas City. "You're always trying to figure out how much you can do to improve. That's always your mentality – you have to fix the players, the [assistant] coaches, the team. But when you're the head coach, the last person you usually worry about taking care of is you."

Edwards learned that lesson both as a player and a coach. He was a defensive back with the Eagles from 1977-85, which gave him a front row seat for Vermeil's meltdown following the 1982 season. Edwards remembers constantly hearing veteran assistant coaches complain about how maniacally Vermeil approached the job. It wasn't uncommon for Vermeil – who was 39 when Philadelphia hired him in 1976 – and his staff to spend a couple of nights a week in a hotel just to get an edge on preparation during the regular season.

Vermeil lasted seven seasons at that unrelenting pace. He actually became so consumed with his job that one afternoon in 1982, after staying up all night and finalizing the team's practice schedule for the day, he couldn't stand up from his desk chair. "It was an emotional thing," said Vermeil, who spent 15 years away from football before returning to coach the Rams and later the Chiefs. "I was completely drained.

"I'd lose on Sunday, and I'd spend three days worrying about what I had to do win the next game," he continued. "And the enjoyment of a win would last a half-hour. But I'm not unique. I know two Hall of Fame coaches who came to me and talked about going through similar problems. I told them that there's only so much you can do. It's like an engine. You can blow up a Porsche if you drive it too hard, and a football coach is no different. You have to find a way to turn it off."

More coaches today are trying to take that approach. While Vermeil admitted that he grew up in an age where "you were judged more by how hard you worked rather than by what you did," today's team leaders seem to be more interested in striking a healthy balance. Lewis routinely reminds his assistants to make time for daily exercise and their families. Even if that means missing practice to make a college visit with a child, Lewis supports his coaches doing that, and he's backed by the Bengals' ownership.

Technological advancements also have made it possible for Lewis to spend more time at home – because he has the same equipment there as in his office – but he still is improving in other areas. "When I'm around normal people, I still have to remind myself about what I should do," said Lewis, who is in his 11th season as head coach of the Bengals. "I get so used to eating while standing up during the regular season that I have to remember to not do that when I'm outside work. It's important that I'm not done eating before [other people] even get their meals."

Other factors in today's world create an environment where coaches should have an easier time relaxing. The current collective bargaining agreement is especially strict when it comes to the amount of time players can spend practicing in the offseason. It's not uncommon for some head coaches to employ 15 to 20 assistants on a staff, meaning there's more reason to delegate. "The staffs are getting bigger now, so there's more time, but it's really just a choice," Fisher said. "It involves discipline, too."

The encouraging sign for the profession is that more head coaches scoff at the notion that working around the clock is what separates great coaches from ordinary ones. Edwards, for example, was heavily influenced by the years he spent working along with Dungy on Schottenheimer's Kansas City staff in the early 1990s. Schottenheimer was such a workaholic that the coaches would hold training camp meetings at midnight because that's when they had enough spare time. Dungy was so turned off by that approach that after becoming the Minnesota Vikings' defensive coordinator in 1992, he would occasionally call Edwards, who was still working for the Chiefs, after 10 p.m. and say "I know what you're doing ... and I've already left."

Over the years, other coaches have taken a similar approach, largely because they've learned from those who came before them. Lewis often remembers the advice Dungy gave him years ago, that "you can't worry about every little thing in your preparation that you end up chasing ghosts." Others have shown the preference to step away from the pressures of the game at relatively young ages. Cowher was 49 when he retired from the Pittsburgh Steelers, Dungy was 53 when he stopped coaching in Indianapolis. Gruden, now 50, has yet to find a reason to leave ESPN's "Monday Night Football" booth for a return to the sidelines after five years away.

Edwards also discovered how hard the job could be in his final two seasons as head coach of the Chiefs. He was running a team in the midst of a major rebuilding process that he calls the toughest period of his eight-year run as a head coach. "When you win, there's energy in the building, but you have to bring that energy as a head coach when you lose," Edwards said. "Every morning, my routine was the same. I got up. I worked out. And I had to energize an entire building, because I was the face of the franchise. You still have to work. The key is knowing how to work."

That actually is something Fox knew before his heart problems intensified. He said his passion for the game remains strong and that he feels better now than before the surgery. Fox also dismisses the notion that his job is stressful. In his eyes, the surgeon who performed his operation has far more pressure on his hands.

What Fox can't deny, however, is that he's part of a profession where men sometimes need to be reminded of their limitations. That lesson was reinforced during the month he spent away from the job he so dearly loves. "When you spend four weeks with your wife basically working as your nurse, it's going to bring you closer," Fox said. "Three of my four children were home as well, so I saw what they were going through. They didn't want to lose me, and I wasn't ready to go. Something like that definitely opens your eyes to life."

ESPN St. Louis Rams reporter Nick Wagoner contributed to this report.