GaryPinC
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Posts posted by GaryPinC
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2 hours ago, pennstate10 said:
A stress echo can give additional info as to whether left ventricle outflow tract obstruction occurs with exercise (stress). it may give helpful data in borderline cases
See https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/17/09/17/role-of-exercise-testing-in-hypertrophic-cardiomyopathy
Since commitio cordis is a diagnosis of exclusion, I’m guessing his docs will do all they can to rule out alternate diagnoses.Thanks for the info and excellent reference. I gather from the article that this type of echo is really needed to assess limitations of physical activity including assessing transient blood flow restrictions during exercise.
So I see where you're coming from with what may have caused the arrhythmia in this case.
I'm still left with my original question that isn't this degree of hypertrophy measurable with a routine echo, even when Damar was sedated?
Is the exercise echo is more of a secondary assessment?
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1 hour ago, BillsFanSD said:
From what I've been told to expect, this outcome is on the very upper end of what was possible.
It's probably fair to start thinking more about what this injury means for Hamlin career-wise. Obviously that wasn't the main focus yesterday. If this was really commotio cordis, my understanding is that there's excellent chance that he returns to football. Things change if there's an underlying heart issue that nobody knew about. That will all get sorted out of course.
That's interesting, I haven't read all the thread, is there a reputable source that he can play again if it is indeed commotio cordis? Routine hit to the chest on the T-wave upslope will induce a fatal arrhythmia.
I would think that would be the end of his football career or is it somehow manageable?
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55 minutes ago, pennstate10 said:
Huh...
As stated, I think that your linked video was a good general explanation of commotio cordis and potential complications and therapies.
I disagreed with your analysis with respect to Hamlin, as quoted here:
"This video is great as it confirms the diagnosis, but it really does a fantastic job showing the complications from cpr;the possible development of acute respiratory distress syndrome associated with cardiac arrest ; he mentions two resuscitation attempts; he shows the changes in the lungs on X-ray and why 100% oxygen was needed"
1) Diagnosis of CC wasnt confirmed, in fact, Cincy ICU docs specifically stated that they have more evaluation to do before arriving at a dx. CC is a diagnosis of exclusion. I'm not saying that CC isnt the correct diagnosis. But have the docs ruled out hypertrophic cardiomyopathy, for instance? This can be difficult to rule out without genetic testing and stress echocardiograms. Hard to do a stress echo on an intubated patient.
2) There werent 2 resuscitation attempts.
3) The CXR shown wasnt Hamlin's, but an example of a patient with ARDS (who in all likelihood didnt have CC).
Are you a physician? I am. Most docs I know are careful with their words, and would never state a diagnosis was confirmed based on what TV docs were speculating.
Great news that Damar is awake and communicating. Thats really, really promising re: neurologic status. Hopefully they will be able to extubate him soon.
Thanks for your input. I was curious, why would Hamlin need a stress echo to diagnose hypertrophy? If it had progressed to the point it contributed to the fatal arrhythmia on a routine hit, wouldn't it show up on routine echo wall dimensions and FS/EF measurements?
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47 minutes ago, Beck Water said:
PR and media relations management is normally not something they teach in medical school
I thought those two physicians did an INCREDIBLE job. They were very generous in recognizing the Bills physicians and trainers, gently emphasizing the impact of immediate bystander CPR and defibrillation on a positive outcome, and also firm but clear on refusing to provide details of exact timing of the arrest/resuscitation that remains to be reviewed, or detailed results of medical tests that are nobody's business but his family's
Trying to summarize some notes I took:
Initial response:
1. initially had pulse when trainers reached him, pulse disappeared under their initial care
2. had one round of CPR and one round of defibrillation to restore a pulse (ROSC, return of spontaneous circulation)
3. had a "textbook" EMS response including airway maintenance and intubation prior to transport to hospital
4. no details about why/how long the ambulance remained in the tunnel, but did share that Hamlin was intubated and had airway maintenance prep once he was inside the ambulance.
5. no tracheostomy (hole in the throat to insert a breathing tube, this would be done if there were an object lodged in upper airway or if there were neck trauma where swelling would threaten the airway).
6. no broken jaw.
7. was sedated, placed on ventilator and placed in prone position due to ARDS (acute respiratory distress syndrome) which was explained as an inflammatory response interfering with gas exchange in the lungs.
8. hypothermia protocol was used
Current status:
1. Still on ventilator with breathing tube in place, so can not speak.
2. Is communicating by moving shaking head or nodding (important detail - means they aren't worried about neck injury), by squeezing hands, and by writing on paper on clipboard.
3. He asked early on who won the game? Doctor said they told him "you did, Damar, you won the game of Life".
4. Parents and family and members of the Buffalo Bills staff are with him
5. Said he's been holding lots of peoples' hands - he's held doctor's hand, family, Bills
6. They can very much feel the prayers and the well wishes surrounding Damar and his family.
7. Said his family is wonderful and they wish everyone had a family like that.
8. Said Damar has been told he's got a lot of toys to buy when he gets out of hospital
Next steps:
1. Focus is on improving his respiration and restoring his ability to breathe without the ventilator
2. Asked if Commotio Cordis was the cause of his cardiac arrest. Explained that Commotio Cordis is a "diagnosis of exclusion" and they will be conducting further tests to rule out other causes of sudden cardiac arrest before that diagnosis would be made.
3. Asked about concussion. They explained that no head injury detected, but concussion is a neurological diagnosis and since he's been sedated on a ventilator that evaluation could not be made.
4. Asked several times about what the best outcome would be, and what kind of rehab he would need or timeline. Said the best outcome would be to return to the state he was in at 8 pm Monday night (didn't sound as though they rule that out) but it's too soon to tell what kind of rehab would be needed or what the timeline would be
Hope this is helpful to anyone who didn't have time to listen to the whole thing.
Thanks, this is a great summary. I only caught the end. I think HIPPA was a bit of a concern as they wouldn't go into specific tests like echo results and EF. Kind of surprised the questioner identified herself as a cardiologist and proceeded to ask those questions. Seemed a little classless and disrespectful of someone who should know the ins and outs of PHI, IMO.
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4 minutes ago, Nephilim17 said:
I'm sure these guys are tremendously knowledgable and skilled but looking at the two doctors sitting there while the woman was talking... they looked like football fans with backward caps on in scrubs. I could totally picture them in jerseys and knocking back giant cups of beer. Maybe even jumping on a table.
Can you picture what I mean?
No disrespect just some levity about these two amazing men who helped Damar start this amazing recovery.Haha, I admit you can't see the back of their heads but those are most likely surgeon's caps and facing the proper direction. I like your take better though!👍
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14 minutes ago, Gugny said:
This tweet should be pinned so all of the guessing/theorizing/pretending to know what's going on stops.
One of our ER docs was in today and I got to catch up with him. One of the smartest, analytical guys I know, around 60 years old. He felt from the film that it fits the profile of commotio cordis. He also mentioned UC Medical Center is a leader in neurological issues and couldn't be in better hands.
Also, docs said Hamlin had ARDS (somebody page Mr. Weo) and that he was administered TTM (therapeutic hypothermia).
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4 minutes ago, dave mcbride said:
Apparently there are gradations from 1-5: https://www.ahajournals.org/doi/10.1161/CIRCHEARTFAILURE.108.828095
1 and 2 are considered "neurologically intact." 1 is no effects, and 2 is moderate dysfunction. Non-NIS categories are 3, 4, and 5.
Thanks, that's a great source but I'm not sure if it's the standard of care (NIS) and how you quantify the moderate dysfunction, especially in Damar's case compared to time of discharge.
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13 minutes ago, YoloinOhio said:
Yep, I can tell you from personal job experience that you can see the bluish color change back to flush or pink just by doing CPR. I definitely wanted to dovetail with others have said and encourage everyone to be CPR-certified. It could be the difference.
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6 minutes ago, Fan in Chicago said:
Another stupid question - does "neurologically intact" mean that there will be no long term negative effects on brain function?
Great question, and I don't truly know the scope of what it means. Certainly critical autonomic functions and gross measures of brain activity/responsiveness.
Physicians/neurologists would be best to answer this question.
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F**king great news! My impression is lung damage/pulmonary edema is the driving factor now, which should be recoverable. 🙏 🙏 🙏
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11 minutes ago, Herc11 said:
In my understanding, it is not about damage. It about the timing of the blow. If the blow occurs at the exact millisecond when the heart is in a specific point of the T wave it can disrupt the electrical signal causing arrhythmia, V fib.
The same principal can occur when delivering a shock to restore the heart from certain arrhythmias. For instance, in v-tach or SVT before shocking you MUST use the "sync" button before delivering the shock. This allows the device to detect the rythtym and deliver the shock at the appropriate time. If it is not used and you deliver the shock during a point in the T wave, you can put the heart into v-fib which is worse than the rythym you were trying to correct.
In v-fib the heart is basically just quivering so the use of "sync" doesn't apply.
Not sure if you can even get sync to work with v-tach 😉
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1 hour ago, Mr. WEO said:
Unfortunately oxygenation isn't an indicator of much. Assuming normal lung function and adequate cardiac output, he should have little difficulty oxygenating on the vent. The key moment isn't taking him off the vent.
There aren't necessarily going to be "good/improving numbers" in this scenario, unfortunately. All that matters is what will be his mental status as the hypothermic therapy and sedation are stopped. His heart can, right now, be fully back to baseline (no doubt he's had at least one echocardiogram since he went down)--the issue is did he suffer an anoxic brain injury before spontaneous circulation was restored in the filed.
Is there one key moment? I would say it's a series of them. "Assuming normal lung function" is not smart after a patient had an arrested heart, been defibrillated, had CPR and is on ventilator. To add to what Redtail Hawk posted, varying degrees of acute pulmonary edema is not uncommon in this situation.
Oxygenation coupled with CO2 levels confirms whether or not the lungs are properly exchanging and functioning. That's pretty damn important.
To take the patient off ventilator and see their breathing reflex (and autonomic nervous system) functioning normally is a huge moment in my little world. You're not wrong that assessing overall brain function is very important but if the autonomic nervous system is compromised, well I've never allowed an animal patient make it back to consciousness. There are different degrees to anoxic brain injury, many quite recoverable, but autonomic compromise is a dark indicator IMO.
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1 hour ago, Beck Water said:
Fantastic post, Thanks! So basically, any cardiac arrest/ROSC leaves the patient susceptible to re-arrest?
But now we have reports that he did not re-arrest so that's great if true.
On the ambulance, I'll give my perspective as a former EMT which could be full of wind, but whatever. I think the ambulance most likely waited because the emergency physician or one of the paramedics was performing a procedure, in consult with the trauma center, that was quicker and easier to perform while the ambulance was not in motion. You know how using your cell phone is hella easier when you're sitting still vs. jouncing around a city street? Yeah, That. It's kind of an unusual situation BECAUSE there is an emergency physician and airway specialist and a broader range of equipment and drugs available to them at the stadium. So the physician/paramedics could well have been in contact with the trauma center and they mutually decided to do whatever they paused to do vs. waiting 10-15 minutes to arrive at the Trauma Center.
It's my understanding that since Kevin Everett and Ryan Shazier's injury, the NFL is "all in" on hypothermia treatment. They reportedly started an IV - I'm told that chilled IV fluids are now maintained at Pittsburgh stadium, so quite likely elsewhere as well - and they could well have packed him in cooling packs or ice to start hypothermia, stadia most certainly are supplied with ice and blue ice packs. They might even have paused to do this before heading for the ER.
Sal C reported that Damar's mom was on her way down while he was still on the field, standing behind the Bills bench saying "I want to be with my son" and he summoned Dane Jackson who got the attention of the Bills Chaplain, and they then worked with security to get her on the field ASAP. I think she just got down to the while the ambulance was still there so they put her in, and if the ambulance had been ready to leave before she got there it would have left and security would have put her in a car and followed.
Thanks for all your input and feedback! I definitely appreciate your ambulance perspective, but as a former EMT would you want the mom in there if things go south?
To answer your question, yes, but so, so much goes into it. Things like myocarditis/pericarditis temporarily changes ERPs and sensitivity of the heart to arrhythmia.
In Hamlin's case, young and in top shape, with no significant risk factors you would anticipate restoring sinus rhythm quickly and minimal chance of rearrest. But we don't know what underlying genetic and environmental factors there were. Immediate CPR is a big help also, but the longer it takes to restore sinus rhythm the odds you can't bring the person back rise precipitously. My understanding from the docs is humans fall off the cliff of being able to resuscitate very quickly. Just happy they got him back, 8 minutes is a fairly long time but they were doing CPR for most of it.
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2 hours ago, Kmart128 said:
My question is if it's true his heart stopped at hospital does that indicate that the hit to the chest didnt necessarily cause the heart issue. From my understanding based off what these doctors are saying is a hit to the chest causes the heart electrical sustem to get out of whack. But if its started again with CPR or AED then it should go back to normal and its just a case of how much damage is caused. If his heart stopped again does that mean there is something underlying or could the first cardiac arrest cause multiple?
I work in cardiac research where we study rearrest and also reperfusion injury primarily to the brain. I am not a doctor or health professional, just a bench researcher. But a big part of our work involves animal models with clinical electrophysiologists and ER docs.
I can offer some perspectives and hopefully will keep it from getting into the scientific weeds.
The short answer to your question is the first cardiac arrest could cause multiple arrests, but it's truly an individual response. The second the heart stops, in some corners of the circulatory system blood begins to clot immediately raising the risk of stroke and a massive inflammatory reaction is initiated. The body quickly becomes hypoxic with reactive oxygen species (ROS) which damage DNA, RNA, proteins and can cause cell death.
In Hamlin's case, one could easily surmise he quickly became hypoxic given the physical exertion of the game.
Also keep in mind that just because you restore sinus (normal) rhythm doesn't mean the heart is beating normally. What usually happens post-arrest is despite the normal rhythm, electrical contraction(depolarization/QRS complex) is incrementally slowed(widened QRS complex) and relaxation (repolarization/T-wave) is usually a mess (ST elevation, elongated/elevated T-wave). At this point the patient can be very susceptible to rearrest. And this period can be as short as a couple minutes to nearly an hour in my animal model experiences.
Anyways, from my perspective, putting an arrest survivor under therapeutic hypothermia is about mitigating and controlling the inflammatory damage while also slowing the metabolic processes and the heart to hopefully prevent more arrests.
In terms of the brain, the inflammatory reaction compromises the blood/brain barrier, allowing blood and inflammatory cells into the brain to kill brain cells. The first 24 hours are critical as the damage and cell death will evolve over the next couple of subsequent days. Again, therapeutic hypothermia is crucial in arresting and limiting this damage.
I was in disbelief that the ambulance waited even 1 minute to allow Damar's mother to ride along. Getting him to the medical center and started cooling is critical. I just thank God he didn't rearrest in that ambulance with his mom right there.
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On 12/23/2022 at 1:36 PM, cle23 said:
Blazin Burgers is just 1 location. They had 2 for a couple years but the 2nd location was tiny and apparently they couldn't keep workers.
I've never tried Swenson's, though it is fairly local. About a half hour drive for me.
I'd put Swenson's at the top of the "luxury fast food burgers" and that's it. Reasonably tasty with some brown sugar added to the beef, they have a large variety of burger and drink styles. And fried mushrooms as a side. Bonus points there! People around Akron swear by them though. But thanks, if I'm ever down around Dover I'll look Blazin Burgers up.
Best burgers: Milt's out in Moab Utah: https://miltsstopandeat.com/ You can choose between buffalo or beef and he locally sources as much as possible. Built-in quality in a small Diner.
Best restaurant burgers: Back in the '90s, I always felt Ruby Tuesday really did a great job with Burgers. Haven't been to one in at least 15 years as they've died out a bit here in Cleveland. But these days any place that'll cook a legit medium rare is a contender.
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18 minutes ago, SirAndrew said:
Fair, I agree the Dawgs brought their C game on defense, and it took Stroud having the game of his life to hang with them. I shouldn’t completely dismiss coaching because those two factors. I think the emotional element clouds my analysis with Big Ten football. I’m just tired of Big Ten teams inability to beat the big boys in the playoffs, with the exception of the OSU champions in 2014. OSU at least showed up to play last night.
I don't agree that Georgia brought their C game on defense, OSU was just that good. Kirby Smart even said post-game OSU probably should have won. Day was masterful at keeping them off-balance.
OSU was equal to UGA last night, just unlucky. Michigan's performance (poor coaching and preparation) were more typical of why the Big10 under-performs and is disrespected.
If Day moves forward coaching like this, I don't think Michigan wins 2 years in a row anymore. Harbaugh's coaching is not adaptable enough and lacks depth.
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1 minute ago, SirAndrew said:
Yes, both Big Ten teams were heavily out coached .
Have to disagree with you on OSU. I thought Day called a great game against a loaded and always dangerous Georgia team. Stroud's lack of blitz recognition and being too content to kick from around the 30 were what killed them.
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3 hours ago, Buffalo Barbarian said:
Should be Michigan vs Ohio St in the championship
No. Michigan was poorly coached, slow to adjust,and routinely made things worse with poor playcalling. They got what they deserved.
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1 minute ago, Boatdrinks said:
He’s short half a foot
What. He was short when OB
Terrible reversal
Ball crossed the line before he hit out of bounds.
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2 minutes ago, Simon said:
This might be the best game I've ever seen Ryan Day call.
That was a masterful drive to start the second half.
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OSU offense, most importantly the coaches, came to win. Now can the D stop the dogs and slow them down enough?
Should be a classic if OSU doesn't get worn out.
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8 hours ago, Solomon Grundy said:
Manuel was more of a "franchise QB" type due to his mannerisms. I totally think that EJ was ruined by the coaching staff of Saint Doug
Manuel left the Bills for the Raiders and in 2019 joined the Chiefs with head coach Andy Reid. He wasn't ruined, he just didn't have what it takes.
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4 minutes ago, Gugny said:
Hue's record was 1-31 because the Browns wanted it that way.
And yes ... I absolutely blame Mayfield for Hue being fired when he was fired.
I live in Cleveland. Hue Jackson was a pathetic joke of a head coach long before Mayfield even arrived. You could be Hue's best friend in the entire world because he totally enjoys warping reality to deflect blame just like you.
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1 hour ago, Gugny said:
Did we also forget that Freddie Kitchens was a HC because Baker Mayfield chased Hue Jackson out?
😂 Hue's record was 1-31 his first two years, 2-5-1 when he was fired (mid-point) and you blame Baker?😂
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Damar Hamlin - Now (1/11/2023) discharged from Buf Gen & “recovering at home”
in The Stadium Wall
Posted
Thanks, I'm not a doctor either but the ER doc I work with thought it at least appeared to be a classic example of CC with the way it went down. Certainly we don't know the cause yet, but I have trouble agreeing with your docs that CC recurrence would be an extremely low probability for a professional football player. If they don't have a way to prevent recurrence, I'd say end of career.