Dr. Kohli On Damar Hamlin's Cardiac Arrest

On January 2nd, during a Monday Night Football Game, Buffalo Bills safety Damar Hamlin suffered cardiac arrest after absorbing a helmet hit the chest. The world stood frozen as many feared for the worst, but fortunately, following four days in the ICU, Mr. Hamlin is now discharged from the hospital and seemingly doing well.

In this interview, DocWire News Managing Editor Rob Dillard sat down with Medical Lead Dr. Payal Kohli to discuss the incident. Dr. Kohli discussed her initial reaction, the probable cause of Hamlin’s cardiac arrest, the prompt medical response that saved his life, and about the dangerous COVID-19 vaccine conspiracy theories some are linking with the incident.

Rob Dillard: I’m Rob Dillard, with DocWire News. Joined today by DocWire News medical lead, Payal Kohli. Thank you so much for joining us. As all the nation knows, on January 2nd on Monday night football game between the Buffalo Bills and the Cincinnati Bengals, Bills’ player Damar Hamlin went in for a seemingly routine tackle, he took a helmet to the chest. He got up pretty quickly, seemingly fine, but within a few moments he collapsed flat on his back. Dr. Kohli, what was your initial reaction to Damar Hamlin collapsing? As a cardiologist, did you immediately suspect cardiac arrest?

Dr. Payal Kohli: It was so dramatic to see it on camera and actually see it happen. And yes, that was my immediate thought, because the way that it happened when he stood up and you could actually see the second that his heart stopped beating because the prior heartbeats had kept blood going to his brain for just a couple of seconds. And then, he took a stumble backwards and fell backwards from a standing position, which almost certainly means loss of consciousness for a dramatic reason, given that he had just sort of been hit in the chest, that was my first immediate thought was that could that have triggered some kind of an arrhythmia that then resulted in his cardiac arrest. And I was just so grateful that he got that high quality CPR that got started right away.

Rob Dillard: Absolutely. And while speculation continues around exactly what happened, most are seen to be pointing to a commotio cordis. So, can you explain what exactly is commotio cordis, and how does it occur? And do you suspect that is what occurred?

Dr. Payal Kohli: Commotio cordis has been around for a long time and we’ve really been underdiagnosing it. Because, we often, in the beginning stages didn’t even know that that’s what was happening. And really, if you break down the words, it comes from Latin, commotio means agitation and cordis means of the heart, so agitation of the heart. And so, really, essentially, what it is, is that when we have a depolarization of the electricity in the heart, that’s when the heart muscle squeezes, we then have a reset that occurs and that’s called the repolarization period. Normally on an EKG that’s characterized by the QT period, when the heart is kind of resetting for the next heartbeat. And in that QT period, there’s a vulnerable period, very small, some say 10 to 20 milliseconds period where the heart is susceptible to basically have a misbehavior or go into a ventricular arrhythmia if it receives some kind of a disturbance or agitation.

So, commotio cordis is ought to occur when you have essentially the perfect storm where you have some kind of trauma or blunt trauma to the heart at the right spot. So, the heart has to be sitting in kind of the right spot in the chest and at the right phase of that cardiac cycle when the heart is susceptible. And what it does is, it causes almost immediate ventricular fibrillation. Now, the opposite is also true. There’s something called a precordial thump, where you can thump somebody on the chest and if you do it at the right time, you can sort of almost reset the heartbeat as well and thump them out of ventricular fibrillation as well. So, commotio cordis, we feel we’ve underdiagnosed it because a lot of times there’s no structural or electrical abnormality present on autopsy. But now we’re seeing increasingly, especially in athletes who get chest trauma and then are found to have no electrical abnormalities or anything that that may be the cause.

Now, in Damar Hamlin, it’s really hard to tell, because I really need to know what his EKG and his echocardiogram look like. In other words, I would love to see if his cardiac structure and function are normal. Does he have a genetic cardiomyopathy, like hypertrophic cardiomyopathy or ARVC, arrhythmogenic right ventricular dysplasia, that predisposes him to cardiac arrhythmias? Does he have an electrical channelopathy, such as a long QT syndrome where his repolarization period is a lot longer? And that could predispose him potentially to have a higher risk of arrhythmias. Was he having some kind of an electrolyte abnormality? Because when you’re an athlete and you’re running around on the field, your stress hormones are revved up, you can also become dehydrated. You can have changes in your calcium, magnesium, potassium homeostasis, that can also potentially increase your risk of arrhythmias.

Rob Dillard: Very interesting. What efforts would you attribute to the medical staff saving Mr. Hamlin’s life? Because Bills’ medical staff was extremely prompted in responding.

Dr. Payal Kohli: I think this is a testament to the fact that quick high quality CPR saves lives. And we saw that in action here. There are reports that a defibrillator was used, which attest to the fact that probably an arrhythmia was involved and it was used in a timely fashion. And then of course, they did something called therapeutic hypothermia, which is cooling of the body for period of time after the cardiac arrest. And that can protect from inflammation and other types of injury that can occur to the organs after an arrest. So, I think the combination of all of those factors and the fact that he was 24 years old, and young and healthy, had good, healthy organs, all of those together have really given us this amazing result where we see him walking around and essentially feeling good back to normal with no long-term neurological sequela. I was also really pleased to see the fact that even though he fell backwards from a standing position, he didn’t seem to sustain any spinal cord trauma or any kind of injury, which certainly could have happened with the type of fall that he had.

Rob Dillard: Yes, turned out optimally well. Next question. I know this isn’t easy. Are there any precautions that the NFL and other leagues can take in the future to reduce such a risk?

It’s been really controversial about screening athletes, because we know that sudden cardiac death occurs at a rate of about 300,000 to 350,000 cardiac arrests a year. And we know that some of those are concentrated in athletes for many of the reasons that I articulated, that their stress hormones are revved up, they’re playing a game that could be electrolyte depleted, and then they have trauma and such that occurs too. So, whether we should be changing our screening in athletes is something that’s remained controversial in the cardiology community, because you really have to try to balance here. You have to balance, obviously, finding disease before it manifests itself on the field against getting some false positives and pulling an athlete that has a lot of talent from play and preventing them from being able to compete or to perform in athletics.

And so, in Europe, the screening guidelines actually do recommend screening ECGs or electrocardiograms for athletes before competitive play. Some places, they even do echocardiograms to look at the cardiac structure and function if the EKG is abnormal. But here in the United States, the screening is based more on history, really looking at family history of sudden cardiac arrest, personal history as well, and then selective use of electrocardiograms and echocardiograms in athletes. So, I think that this has raised the conversation, again, of what we ought to be doing, whether or not more aggressive screening is warranted, but I think it’s a really delicate and difficult situation with a lot of factors to consider.

Rob Dillard: Thank you, Dr. Kohli. Next, unfortunately, there’s a faction of conspiracy theorists who tried to link Mr. Hamlin’s incident to the COVID-19 vaccine. What is your reaction to such thinking, and is this kind of ideology dangerous?

Dr. Payal Kohli: Honestly, I’m very disgusted. I’m disgusted by these people who I believe are opportunists that are trying to use poor Damar Hamlin’s cardiac arrest as a way to propagate their political agenda or their personal agenda or to get a platform or whatever it is that they’re trying to do. But I think the biggest casualty of this is not just that you feel like someone’s taking advantage of somebody else’s situation, but also that they’re spreading gross misinformation. And there are a lot of people now who are concerned about getting the vaccine because of this misinformation. And I really want to put their minds to rest, because in the Vaccine Adverse Event Database Reporting, there has been no link between an increased risk of cardiac arrest as a result of the vaccine in patients who did not get myocarditis. Now, we know that the myocarditis is a potential link for heart inflammation that can occur, but there’s certain things to keep in mind.

The first is that the risk of myocarditis from the vaccine, especially, after those first two doses, which are close together, the booster doses that are spaced farther apart, is substantially lower than the risk of myocarditis from the COVID infection itself. In fact, the American Heart Association says that in unvaccinated people, they’re 11 times more likely to get myocarditis from the infection than if you’re vaccinated. So, that is something to keep in mind, that if you’re more likely to get it from the infection than the vaccine, then really it’s difficult to elicit that sort of relationship. And the second thing that I would say is that the vaccine itself has actually restored our life to normal. And that’s something that I think we’ve taken for granted.

Now, the American Heart Association has said, over the last two years, during the COVID-19 pandemic, the total number of cardiac arrests and cardiac deaths has actually gone up. But let’s talk about why that is, because it’s not gone up because of the vaccine, it’s gone up because of the infection for the reasons that I just articulated, it can increase myocardial inflammation, it can increase vascular inflammation, but it’s also gone up because of lack of access to care. Lot of people had disruptions in their care because of the lockdowns, they presented to the hospital later, they didn’t get their chronic diseases managed, they presented late with their heart failure or their acute coronary syndrome. So, we have seen an increase in cardiac mortality in the last couple of years, which has been unfortunate, but the reason for that according to the AHA is, not a result of the vaccine, but actually a result of the infection and all of the socioeconomic changes that occurred because of that.

Rob Dillard: Thank you so much, Dr. Kohli. Thank you so much for dispelling that conspiracy theory. What are some key takeaways that we can learn from this incident?

Dr. Payal Kohli: I think, the biggest takeaway for me, my family members, my patients, my colleagues, is that every single one of us needs to learn CPR, and we need to learn how to do high quality CPR, because one day it could double or triple somebody’s chances of survival if you give them high quality CPR right away. And the American Heart Association has actually looked at sixth graders learning how to do CPR, and what they found is that the majority of sixth graders can even learn how to do it. So, I’m even talking about children, teenagers, and adolescents starting to learn this life saving skills. So, that’s the biggest takeaway, is that high quality CPR works. The second takeaway is what we touched on earlier, is that perhaps we ought to start looking at our athletes and not just thinking about their orthopedic risk, which we talk about a lot, not just thinking about their neurological risk, which we talk about, with repeated trauma to the brain and what it means for their long-term neurological risk and risk of dementia.

But we also need to start focusing a little bit more on their cardiac risk and really thinking about how we can screen them in a way to really minimize the chances of something like this happening to other athletes. I’m curious to hear what happens with Damar Hamlin’s case, what his EKG is, echocardiogram, and other such findings show. We have had athletes in the past who have had commotio cordis, hockey players or softball players or other types of athletes, and then gone back to play. And so, with him, it’ll be interesting to see what his underlying reasons were, whether or not his medical team is going to recommend an ICD or defibrillator for his cardiac arrest and whether or not he returns to play.

Rob Dillard: Thank you so much for your time today talking about the Hamlin case.