When the First Down Becomes the Worst Down

Twenty years ago, at the age of 27, Boston Celtics player Reggie Lewis collapsed and died on the basketball court. Whenever a young athlete collapses on the field of play, the community cries out for a solution. The most common causes of death in young athletes are cardiac-related issues – an electrical abnormality, a vascular malformation, or a hypertrophic cardiomyopathy.

The comprehensive screening of all student athletes is one possible solution, but mandating such procedures may be prohibitively expensive and intrusive. However, for some young people – i.e., those with a history of unexplained fainting, who experience chest pain or shortness of breath, and/or who have a family history of sudden death – comprehensive screening certainly would be appropriate.

Survival Rates & Authoritative Studies

According to the American Heart Association’s current CPR (cardiopulmonary resuscitation) Statistics Fact Sheet, nearly 383,000 out-of-hospital cardiac arrests (OHCAs) occur annually in the United States. Moreover, the U.S. Centers for Disease Control and Prevention (CDC) reported in 2010 that, nationally, only about eight percent of all people survived who had experienced cardiac arrest when medical staff were not present.

Fortunately, for those who collapse because of an electrical abnormality known as ventricular fibrillation, an automatic external defibrillator (AED) can serve as a lifesaving device. In fact, the same 2010 CDC report also pointed out that the survival rate doubles or even triples when an AED is used to fire an electric charge through the victim’s heart – and, by doing so, forces the heart to settle back to a normal heartbeat.

Many other reports have been published that compare survival rates when AEDs are used and when they are not used. One example is a 2010 study – conducted by the Catholic University of the Sacred Heart in Rome, Italy – which concluded that, “Our meta-analysis add to previous evidence in favour of developing public-health strategies based on AED use by trained lay-rescuers.”

Although AEDs and similar devices have become ubiquitous in many public venues throughout the United States, they are still not widely used. The 2010 CDC report also pointed out that the rate of AED use before the arrival of EMS (emergency medical services) teams “is only 2% for all OHCA events, and 8% for OHCA events in a public setting.” Among the most obvious sports venues with room for improvement in this area are the football fields, basketball courts, and baseball diamonds in communities throughout the country. AEDs offer several benefits in favor of more widespread use. For example, they: are relatively inexpensive; need little or no maintenance; require minimal consumables – often restricted to single-use adhesive electrodes; are relatively easy to operate; and are designed primarily for public access defibrillation programs (for which training in advance is not assumed).

In addition to AED use, a truly effective planning effort must be made to: (a) direct how staff should request help through 9-1-1 calls; (b) determine what if any additional actions should be taken; and (c) identify staff responsibilities to communicate with facility/program leadership. The training required for members of athletic department staff – both in CPR and in the facility/agency plan – would take less than two days of training time per person.

Fortunately, in a 19 May 2011 article, the Mayo Clinic reported that the instances of OHCA in young people are rare. In fact, the Sudden Cardiac Arrest Foundation – a 501(c)(3) organization based in Pittsburgh, Pennsylvania – estimates on its website that there are only around 1,000 cases annually in the United States. This raises an obvious question, “Even if the outlay is modest, isn’t there some other point where the same funding would do more good?” The answer is an emphatic but obviously not definitive “Maybe.” In a community where there is no AED in a senior center or other facility – anywhere there is a higher likelihood of an OHCA, in other words – that community may in fact save more lives with the AED in the senior center than on a high school athletic field.

Avoiding Unnecessary Delays

Regardless of the cost factors involved, it is nonetheless clear that, during and immediately after any cardiac arrest, the first and worst factor that adversely affects the survival of the victim is delay. Almost as soon as the heart stops beating – and blood flow to the brain therefore ceases – the victim’s brain cells become distressed. Within four or five minutes, the brain cells have been severely damaged and most victims already have been lost. On the other hand, numerous studies have shown that the chances for survival almost double when someone starts CPR immediately. In addition, use of an AED, applied shortly after CPR is initiated, further increases the chance of survival.

Massachusetts Governor Deval Patrick signed legislation in May 2012 requiring public schools throughout the state to develop more efficient medical emergency response plans. That legislation, known as “Michael’s Law,” was written following the 2010 death of 16-year-old Michael Ellsessar, a high school student who suffered a cardiac arrest while playing football. The new Massachusetts law requires that local school districts:

  • Develop a method for establishing a rapid communication system and accompanying protocols;
  • Create a way to efficiently direct emergency medical services (EMS) teams;
  • Require implementation of the safety precautions needed for injury prevention;
  • Provide access to CPR and first aid training; and
  • Inform about locations of defibrillators and the names of personnel who have been trained in the use of AEDs.

The factors that make the OHCAs of young athletes different from OHCAs in the general public include the following presumptions: (a) their collapses are more likely to be witnessed at the time, rather than discovered sometime later; (b) school staff members usually are present at sporting events, and can be trained in advance; and (c) the OHCAs of younger athletes are less likely to involve comorbidities – i.e., multiple medical conditions contributing to the collapses. Considered as a package, these factors should and probably would improve the effectiveness of an AED program and, therefore, the survival rate of these young OHCA victims.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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