As a practicing emergency room physician and the senior vice president of emergency and hospitalist medicine at RWJBarnabas Health — or, better said, the person who oversees all 12 ERs in the RWJBH system — Dr. Christopher Freer has witnessed all sorts of trauma throughout his career in medicine.
And even Freer said watching the reactions of the members of NFL’s Buffalo Bills on Monday night while observing their injured teammate, Damar Hamlin, made it hard to watch his TV.
“The emotions of the players made it extremely difficult to watch,” he said.
Freer said he knew Hamlin was in trouble.
“When you see all the players crying like that, you know it is pretty serious,” he said.
Dr. Mario Caruso, a clinical cardiologist with Cooper University Health Care, as well as the founder of the Cooper Heart Institute Sports Cardiology program, felt the same way.
When Caruso saw Hamlin rise to his feet — and then quickly collapse backward without attempting to break his fall — he said he knew this was not the usual sports injury situation.
“That was one of the scariest things you could see,” he said. “Not just from a general population perspective, but also a clinician perspective.
“If somebody’s going down like that, from our eyes, we know almost definitely, that it’s cardiac arrest. And that’s not something you see.”
The event shook everyone who saw it live (as both doctors did) and on replay.
The magnitude of the moment can be measured in many ways — from the deeply shaken TV announcers, who struggled to find the words to describe it, to the league, which took the seemingly unprecedented step of calling the game in the first quarter.
At 2 p.m. Tuesday, there has been little update on Hamlin’s condition.
And, to be clear, neither Freer nor Caruso has any specific knowledge about Hamlin’s care or condition.
But, since this is the story of the day — one in which there are so many questions and so few answers — ROI-NJ reached out to Freer and Caruso to try to bring some insights to the situation.
Here’s a look at the conversations, which occurred separately, but are merged together for the purpose of this story.
ROI-NJ: Tell us your immediate reaction.
Dr. Christopher Freer: I didn’t know what happened at first. When I’m watching football, I obviously always think of head and spine injuries. When I rewound the video, I didn’t see a hit in that area. At first, I couldn’t figure out which player was injured, because there wasn’t one of those types of hits that make you cringe.
But, when I saw the player stand up and then collapse, that looked more ominous. I thought it could be an arrhythmia, which is an irregular heartbeat. You don’t want to guess about something like that when you’re watching it on TV, but I obviously knew it was serious when I saw him collapse like that.
ROI: Some are speculating the injury could have been a situation called “commotio cordis” — which is when the heart is hit in a certain spot during the exact millisecond it is vulnerable. Do you see that as a possibility?
Dr. Mario Caruso: That’s something that you think about more so in baseball with the blunt trauma of a baseball hitting somebody in the chest. But, of course, it can happen in this situation. It’s pretty rare, but it’s definitely a possibility.
ROI: How rare?
CF: It’s like getting hit by lightning.
ROI: Take us down to the field. We were not able to see what was happening due to the crowd of players — and, thankfully, the TV cameras giving the player some privacy. Walk us through how you think the doctors and medical professionals were treating Hamlin?
CF: It starts with something called the ABCs: airway, breathing, circulation. That doesn’t matter if you’re in an ER or on a playing field. You immediately check the airway to see if that’s clear and then you check to see if there’s breathing, so oxygen is getting to the brain. They would have started giving him CPR immediately, if the player wasn’t breathing, and, by all accounts, that’s obviously what they did.
ROI: Talk about administering CPR. How does that go?
MC: It’s very difficult to give CPR. You are essentially trying to make someone’s heart work. That’s not easy. Ideally, people rotate at two-minute intervals. However, if you’re fatigued, you can always essentially tap out and say, ‘I need help.’
That’s why, when you’re giving CPR, somebody should be assessing for the adequacy of the compression — essentially making sure that the chest goes down far enough. If it’s not, someone else needs to step in.
ROI: We’d heard that if given correctly, CPR can be damaging — potentially breaking ribs. We know that would be better than the alternative, but is that true?
MC: It definitely happens if you’re doing CPR correctly. Again, the goal is to essentially get enough force to compress the chambers of the heart to help pump blood throughout the body. And if it’s done for long enough, patients can have cracked ribs or a cracked sternum.
ROI: Would the fact he had football gear on — shoulder pads and other padding — have made it more difficult to administer CPR?
MC: Not likely. Ideally, your hands are directly on the chest and away from the shoulder pads. If there was anything blocking that, they could have cut it off.
ROI: Most accounts said they gave him CPR for at least 10 minutes. Talk about the significance of that time span? Does it give a clue as to how severe the situation is?
CF: It’s not about how severe the incident is, but how quickly a patient potentially can recover. It’s an inverse relationship. The longer the time it takes to get a pulse to return, the worse the outcome. The likelihood of survival diminishes with every minute.
MC: The length of time a patient is given CPR wouldn’t change the immediate workup, evaluation and treatment, but it definitely gives the ER doc, the cardiologist and everybody who’s consulting a thought as to the likelihood for a full recovery because of the overall impact.
ROI: How do you mean?
MC: The things we worry about are not only cardiac in nature. Neurologic recovery is very important. The chances of organ failure also increase from not having a heartbeat. All these things play a role in recovery. So, the longer somebody’s getting CPR, the likelihood of a meaningful recovery decreases.
ROI: Talk about the use of a defibrillator: Why is it used and how effective can it be?
CF: If someone has an arrhythmia and their heart stops, they’re not going to have a pulse and they won’t be breathing. So, as you’re pushing up and down on the chest to help them breathe, someone is getting a defibrillator to put on the chest to see what the rhythm is.
Defibrillators are a tremendous innovation. You don’t have to be a medical professional, you just put it on the person’s chest, and the machine reads the situation. And, if it’s something that’s shockable, meaning a rhythm that you can shock the person back, the defibrillator will give a shock in hopes that the heart goes back to a normal rhythm — and the person suddenly wakes up.
I’ve seen it multiple times. It’s pretty miraculous when it works.
ROI: Was there anything you saw last night that didn’t seem right to you, medically?
MC: No. And part of that is because they obviously had an emergency action plan. All professional sports teams and most NCAA teams, at least Division I facilities, have this. Essentially, it’s how to respond to event like this.
CF: No. The doctors seemed to be there right away and I’m sure they were doing everything they could be doing. I was a little surprised that they weren’t moving him sooner, but the guess is that he wasn’t stable enough — and that they were trying to get him to a point to where they could get him in the ambulance.
ROI: Would a delay in getting to the hospital be a big issue?
CF: Not really. It is a little different being outside the hospital than in the hospital, but the paramedics have similar tools and equipment out in the field. And that’s all they do. They have all the drugs that we have in our emergency rooms.
I’m confident they had something they needed to intubate him, meaning put a tube down his throat to help him breathe. I’m 100% sure they had a defibrillator. I think the delay was only getting him to a point where he was stable enough to be moved.
ROI: The episode certainly will renew the discussion about the safety of football and sports. If you had to talk to a group of youth parents today about sports and safety, what would be your message?
MC: If I were to be talking to individuals, parents, coordinators of leagues about last night, the first thing I would show them are the statistics that point out the incidence of what this was — blunt chest trauma causing sudden cardiac arrest — it is not very common and it exceedingly unlikely. The hit has to be in the right spot on the chest and it has to be a certain power to the chest. All the variables that that go into play make it not very common.
CF: I’m sure it’s going to scare parents, but I’m going to tell them that I have four kids and they all played sports.
I know the violence of football; my son played football. But this just wasn’t one of those types of hits. It wasn’t a neck or head injury. It didn’t make sense to see him falling like that after the hit.
Does this mean you should put your kids in swimming or tennis because they are noncontact sports? I can’t answer that for them. You can get hurt there, too. You can get hurt crossing the street.
ROI: Final thoughts?
MC: One of the initiatives I’m trying to push through at Cooper is developing an emergency action plan for local colleges and high schools so, if something were to happen like this, somebody could have a reasonable chance at survival and meaningful survival at that.
CF: I think the doctors reacted in the right way. How many years of football has everyone watched? I don’t think anyone’s seen anything like this before. I said to my kids in our family chat, all we can do is just say a prayer.