Life in the Time of Covid by Dr. Richard Sternberg

He’s Just ‘Mostly Dead’

Damar Hamlin in one sense is the luckiest undead person in the world. As probably almost all of you readers know, he is the Buffalo Bills player who went into ventricular fibrillation when he tackled an opposing player in the Bills-Bengals game on December 26 in Cincinnati. This was seen on national television by millions. He was successfully resuscitated on the field and rapidly transferred to the University of Cincinnati Medical Center, which is the major teaching hospital in southwest Ohio. He has done so well that he was released from the intensive care unit at UCMC and transferred back to Buffalo on Monday.

There’s a big difference between mostly dad and all dead. Mostly dead is slightly alive.

Miracle Max – “The Princess Bride”

Ventricular tachycardia is the most dangerous of the abnormal heart rhythms. It is the complete collapse of the ability of the ventricle of the heart to pump blood. Disorganized electrical activity causes the muscles of the heart to quiver rather than have a normal sequential beating, and pumping does not proceed.

Without very rapid, successful onset of treatment, death soon occurs. The probability of surviving v-fib is low, especially outside of a monitored episode in a hospital.

Hamlin survived, and apparently without any neurological damage. This is due to the fact that there were more than 20 people almost instantaneously present who had prepared for and had rehearsed what to do if this situation occurred, even down to who would perform the CPR and how his uniform would be removed so that electrical cardioversion (electrical stimulation to shock the heart back into a normal rhythm) could be performed. Every member of that team knew exactly their role in the resuscitation. If one has to develop v-fib outside of a monitored event in a hospital, I can think of no better place for it to happen.

Amazingly, not only did the medical teams of both the Bengals and Bills perform perfectly, almost every other action that happened that night was on point. The game was halted and the announcers and sports reporters did not speculate. It immediately reminded me of how Jim McKay, the lead sportscaster of the 1972 Olympics, responded during the kidnapping and assassination of Israeli athletes from a terrorist attack.

ESPN had very respectful, somber discussion and admitted there was not much that could be said. The hospital did not hold a press conference and left the decision on the release of information to Hamlin’s family, which is the appropriate and legal thing to do (think HIPAA), but were ready to assist the family in this regard.

While I have counted at least 12 causes of v-fib, most either involving preexisting heart abnormalities or medical conditions, in my opinion the most likely was, in this case, commotio cordis. This is a condition in which v-fib occurs immediately due to an object (usually something small and hard like a baseball, lacrosse ball, or hockey puck, though in Hamlin’s case it was a body part of the other player) striking the chest directly over the heart at exactly the right point, with the right force, exactly at the critical moment during a heartbeat.

The term, commotio cordis, is said to translate from Latin as agitation of the heart, though I like to think of it more literally as commotion of the heart. The period of the heartbeat when this can be initiated may be as small as one tenth of one percent of the cycle of the heartbeat. A small number of athletes, mostly amateur, die from this, or rather from lack of immediate on-field care of this, yearly. Since it involves highly localized trauma to the chest wall, mostly in athletes, this is often a young person’s diagnosis.

In any event, Hamlin must have been cardioverted very quickly. Six minutes of lack of oxygen causes permanent damage to the brain. Another indication that the cardioversion happened quickly is that only one person performed the CPR according to statements made before this past Sunday’s game. Current CPR technique recommends, if available, that there is frequent changing of people doing the pumping, since it is very fatiguing. If only one person performed the CPR, it must not have been needed for long.

One needs to acknowledge that the NFL, with the prodding of the Players’ Union, did the right thing in being so prepared for this emergency. Damar Hamlin was able to come back from “mostly dead.”

Post script: I am taking my CPR re-certification course tonight. Probably every person able to perform it should learn it.