The collapse of NFL player Damar Hamlin during Monday’s game highlights the perils associated with pre-participation screening in sports.
Across the U.S., programs are in place in high schools, colleges and professional sports to assess for an increased risk of sudden cardiac death which, if found, typically excludes an athlete from continued participation in competitive sports. However, as we saw on Monday Night Football, despite all the resources available to the richest sports league in the world, we still had a person suffer a cardiac arrest on live TV.
Cardiac screening programs are well-intentioned. They involve a variety of tests evaluating for pre-existing cardiac conditions, such as heart rhythm abnormalities, structural heart disease or genetic cause of sudden cardiac death. However, they require a lot of expensive resources — development of protocols, getting a team of physicians and athletic trainers together, performing and interpreting electrocardiograms (EKG) and sometimes echocardiograms.
The incidence of sudden cardiac arrest among athletes is low, about 1 in 50,000, but because of the recognized tragedy of seeing or learning about the death of a young person through sports, significant time and money is invested in making this a never-event, which is unfortunately very hard to do.
Among NCAA college athletes, only about a third of conditions that cause cardiac arrest can be detected using EKG and echocardiogram. Therefore, a negative work-up in an asymptomatic athlete as part of a pre-participation screening can give a false sense of security. For example, unless the athlete has symptoms which trigger a more in-depth evaluation, coronary artery disease can be missed with EKG and echocardiogram. Furthermore, commotio cordis, a cause of sudden cardiac arrest where a blow to the chest during a vulnerable phase of the cardiac cycle can trigger an arrhythmia, can never be excluded by screening.
The best intervention to prevent sudden cardiac death of our athletes is to have wide-spread availability of people trained in cardiopulmonary resuscitation (CPR). Almost anyone who attends a sporting event of any form can and should know how to do chest compressions. Chest compressions are safe, effective and easy. There is no liability associated with doing chest compressions. There is significant liability associated with not doing them. No high level of training is needed.
Many states required CPR certification to graduate from high school. CPR training is offered through many avenues, such as club sports teams, church socials, work wellness programs. I once taught CPR to stylists in a hair salon. It is easy to learn, do and teach. In fact, most CPR that is learned ends up being used on family members, or people living within the same household. More than anything, even aside from sports, we should want to learn CPR so we can help those closest to us.
Significant emphasis is often placed on the benefits of having automated external defibrillators (AEDs) in public places. These are designed to electrically shock people out of an abnormal, life-threatening arrhythmia. Importantly, their use is as a complement to chest compressions. In fact, the American Heart Association many years ago introduced recommendations for hands-only CPR, with the research showing that this was just as successful as conventional CPR but was much easier to introduce in a timely manner.
The essence of hands-only CPR is that if someone is suspected of having a cardiac arrest, step one is to call 911 and step two is to do chest compressions, until the emergency medical services arrive. Now, in rural communities such as that we have here in Utah, that can take some time, which is likely where the role of AEDs becomes most significant, but the backbone of resuscitation remains chest compressions.
The response on the field to Damar Hamlin’s cardiac arrest was admirable. Trainers were at his side within seconds and CPR was started quickly. Monday Night Football showed us that screening to prevent cardiac events is never perfect, but the response should be.
John J. Ryan, M.D.
John J. Ryan, M.D., is an associate professor in the Department of Medicine, and director of the Pulmonary Hypertension Comprehensive Care Center, at the University of Utah.