Monthly Archives: January 2023

To Play or Not To Play

In last night’s Monday Night Football game, Damar Hamlin, a 24-year-old player on the Buffalo Bills, made a tackle, stood up, and collapsed on the field in cardiac arrest. CPR was administered, a defibrillator restored his heartbeat, and he was taken, still unconscious, to the University of Cincinnati Medical Center, a level one trauma center. As of this writing, he remains in critical condition and there has been no information released as to the cause of his cardiac arrest.

The lack of an official diagnosis, however, does not stop speculation, including my own.

There are a number of possibilities high on the differential (the list of potential causes). Vascular injury (injury to a blood vessel – for example a severed artery, or a ruptured aneurysm) can occur spontaneously or after a forceful blow. A spinal cord injury can occur with a forceful collision, and a severe, high (neck-level) injury can lead to cardiac arrest. An issue within the heart itself can lead to cardiac arrest – a heart attack (blockage of an artery that provides blood to the heart muscle) or a problem with the electrical conduction system of the heart can cause the heart to stop.

Mr. Hamlin was running fast to tackle the ball-carrier. The ball-carrier was running fast as well, and his shoulder hit Mr. Hamlin’s chest as they ran full-force into each other, and you can see effects of the rapid deceleration forces on their bodies as you watch video of the collision. Mr. Hamlin stood up and quickly collapsed.

Because of the timing of his collapse in relation to the collision, and because emergency medical personnel were able to get his heart to resume beating, I think there’s a significant possibility that his cardiac arrest was caused by “commotio cordis,” a phenomenon where a blow to the chest occurs at exactly the wrong time in the heart beat electrical cycle and can lead to ventricular fibrillation (fibrillation is a disorganized electrical firing of the cardiac electrical system which stops the normal, coordinated electrical pattern, and instead of an organized, coordinated, functional heartbeat, you end up with ineffectual random, uncoordinated contractions of cells that do not create a functional heartbeat – were you to touch a heart in ventricular fibrillation, it would feel reminiscent of a bag of worms). A physical blow actually creates an electrical impulse, and this impulse can affect the heart’s electrical cycle just as an electric shock from a damaged electrical cord or downed power line or a lightning bolt can. It can be caused by a baseball or soccer ball to the chest (the sport it occurs in most frequently in the U.S. is baseball), a punch or kick to the chest, a fall onto the chest, etc. at a very specific time when the heart’s electrical system is resetting itself for the next beat. It is rare, because of the specificity of the timing in a tiny window.

If commotio cordis is the cause, the fact that he had immediate CPR and defibrillation gives him the best chance of a positive outcome, and I very much hope that this kid is ok (and yes, he’s a man, but he’s the same age as our middle son, so to me he’s a kid).

In medicine, we are always weighing risks and benefits. Risks of differing treatments. Risks of not treating something. And we all do this in life in general. We assess which potential risks are worth which potential benefits and we live our lives accordingly.

Which brings me to the topic of playing football in general.

I love watching football. The beauty of the strategy, the athleticism and skill of the players, the teamwork, the meticulous planning and also the changing of plans in response to unexpected situations, the constant action – when you know what’s going on, it’s a remarkably fun sport to watch.

I hate watching football. I hate seeing players’ heads jerk sharply when they collide with another player or hit the ground.

I won’t watch professional boxing. I appreciate the skill needed to be a professional fighter. I appreciate the work that needs to be put in, the fitness level, the practice. I cannot ignore that the goal is to knock your opponent out. The objective is to cause a degree of head injury that renders your opponent unable to stand for a full ten seconds. The intent is to harm. I cannot, will not, condone this as a sport.

But in football, the goal is to move a ball across a goal line (or through goal posts). The intent is not to harm. The intent is to move a ball. The intent is not to render your opponent unconscious. But the effect, even if not the intent, can indeed be harm.

I hate CTE (Chronic Traumatic Encephalopathy) – the condition that comes from repetitive sub-concussion-level head hits (or even non-head hits – when you slam into a tackle dummy bag and your body stops, your brain continues to move and hits the inside of your skull, and if forceful enough can then snap back and hit the other side as well) and/or repeated concussions. It’s a progressive brain disorder which can eventually lead to dementia. It occurs mainly in people who participate/participated in sports with repetitive collisions (e.g. boxing, football). It occurs with hockey and soccer as well.

Concussions suck. Spinal cord injuries suck. Knee injuries certainly aren’t desired.

All three of our sons are athletic. All three of them wanted to play football in middle and high school. I told all three of them “no.”

Our sons are athletic. Our sons are not big. Basic physics – when a small guy and a big guy run into each other, the small guy is going to take a lot more force in the hit.

Would they have had fun playing? Yup. Would they have learned things they wouldn’t have learned elsewhere? Yup. Would there have been other potential advantages? Also yup. Were these benefits to my kids worth the repetitive collisions? In my calculations at the time, nope. And if I were to have it to do over, my answer would remain “no.”

But every time I watch the Michigan Wolverines play, I’m watching other people’s children take those risks, and I really enjoy watching. I kinda suck as a human, if you think about that.

But here’s the thing: We allowed our kids to do plenty of things that involved not-insignificant risk. They all ski. They all did track and cross country through high school (dehydration and physical exhaustion are not benign, and runners certainly frequently experience injuries). They all did martial arts (in a dojo where you worked with “partners” rather than “opponents,” and where respect and safety were emphasized, but I’m not an idiot – I am well-aware it was not a risk-free activity). There are plenty of folks who would not allow their kids to take on the physical risks of skiing or of martial arts, but they enjoy watching the competitions in the Olympic games – I don’t think these people are unethical for accepting a risk for others they don’t accept for themselves. We all have our level of risk tolerance, and for so many things, even if the risk isn’t worth it for us, we can appreciate those things (think air shows, or gymnastics, or car racing).

So when one of my friends asked me if I think Damar Hamlin should retire from the NFL after this, assuming he recovers fully, and if the cause of his cardiac arrest was a piss-poor-luck timing of impact and not an underlying cardiac condition, I honestly cannot answer. His risk of continuing to play would be the same risk of brain injury that all players assume, and that I would not want my children to assume.

And the cause of his collapse may be something else. We don’t know yet.

I would like to see football evolve so that there is less collision. One may ridicule me here, but two of our boys played flag football, and it’s a great game. We have technology that we could adapt with sensors on uniforms to make football more of a two-hand-touch type of game. It would be different. But a new football could evolve that would keep much of the strategy, athleticism, and esthetics of the game and mitigate some of the more catastrophic risks.

Note that I said “mitigate” and not “eliminate” risk. To live is to be at risk. But risk mitigation allows us opportunity to do more. A freak accident can happen anywhere, with any sport, and in life in general, but we can set things up so that there are fewer accidents expected.

Risks. Benefits. Intent. Mitigation. It’s a lot to think about.

Again, I hope this kid is ok. And I hope all the players get the professional emotional support they need.