The sports world is reeling after the terrifying injury to Buffalo Bills safety Damar Hamlin during the first quarter of Monday night's game against the Cincinnati Bengals.
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Hamlin, a 24-year-old former star player at the University of Pittsburgh, from McKees Rocks, Allegheny County, went into cardiac arrest after he took a blow to the chest while tackling Bengals receiver Tee Higgins. Hamlin initially stood up after the collision, but then suddenly collapsed on the field. Medical staff performed CPR on Hamlin, restoring his heartbeat before he was taken to the University of Cincinnati Medical Center.
Hamlin was in critical condition in the hospital's intensive care unit on Tuesday, and no significant updates on his health were available by late Tuesday afternoon. As support for Hamlin pours in, NHL Hall of Famer and former Philadelphia Flyer Chris Pronger offered a prayer for the Bills player. He tweeted a link to video of a similar injury he suffered during the 1998 playoffs that caused him to have an erratic heartbeat, or arrhythmia.
At this time, it's not known for sure what caused Hamlin's cardiac arrest. While indications, like Hamlin's age and the impact to his chest that occurred immediately before he collapsed, suggest it could be an arrhythmia, Dr. Aaron Baggish, a sports cardiologist at Harvard Medical School, told the New York Times it is "premature to be definite."
When Pronger was injured — then a player for the St. Louis Blues — he was struck in the chest by a slap shot from Detroit Red Wings defenseman Dmitri Mironov. The puck hit Pronger just left of his heart, initially knocking him to the ground. He got up, took two strides and then collapsed onto the ice.
"My eyes (rolled) back in my head and then I went down," Pronger recalled during a 2015 interview with NHL.com. "At the time, you're young and you don't take it that serious. But as time goes on, you read about these types of incidents and that kids die from it. I was lucky."
The puck that hit Pronger in the chest caused an arrhythmia, which occurs when the electrical signals that control the heart's beats fall out of sync. Pronger remained unconscious on the ice as his teammates and a silent crowd watched in horror.
"It's just frightening to see a man buckle like that," former Blues forward Blair Atcheynum told reporters at the time. "His eyes were rolled back in his head."
Pronger reflected further on the incident during a Tuesday phone call with the Calgary Herald, saying he recognized similarities between's Hamlin's injury and his own.
"I was 23-24 at the time, the same age as Damar Hamlin," Pronger said. "His mom was at the game last night. My parents were at the game in Detroit. A lot of parallels, I thought. I just hope everything turns out right for him."
After Pronger's injury, he was taken to a hospital and evaluated before he was released with a heart monitor that he wore for 24 hours. His doctor didn't find any further irregularities and approved Pronger's return to the ice for Game 3 of the playoff series. Pronger played more than 41 minutes and recorded an assist.
When Hamlin went down on "Monday Night Football," Pronger flashed back to the scene that surrounded him in the moments after he fell to the ice. Via the Calgary Herald:
The next thing I knew I woke up, you're just coming to, my jersey was cut off, I wasn't aware of much, some of my equipment was off, I'm looking up at the retired jersey banners and I don't know what to think. I glanced over to the bench and players were crying, Hully (Brett Hull) was crying. At that moment, no one knows what's going to happen. I think it speaks to the magnitude of the situation. Yes, it's a game, those Red Wings would go to win the (Stanley) Cup that year. There was a lot of bad blood between those teams. A lot of hatred and dislike between those teams. But at that moment, there's a little bit of humanity and understanding of what could have happened.
Though details about Hamlin's injury remain scarce, a number of cardiologists have suggested that he may have suffered from a rare injury called commotio cordis, the same phenomenon used to describe Pronger's injury.
Dr. Khalid Aljabri, a Boston-based cardiologist, tweeted a graphic about the injury and a description of how the heart can be sent into ventricular fibrillation. When an impact to the chest causes this irregular heart rhythm, the lower heart chambers contract in a rapid and uncoordinated manner, disrupting blood flow to the rest of the body. Aljabri said these events are not linked to COVID-19 vaccines.
Dr. Saju Mathew, a CNN analyst and public health expert, said commodio cordis is extremely rare — only about 15-20 cases are reported annually in the United States. It tends to happen most often among young baseball players.
"It has to happen at the right place at the right time in that area of the chest," Mathew said. "We know that this was not a spinal cord injury or a brain injury, because he gets up, and then he falls back most likely when his heart goes into that abnormal condition."
Mathew added that the key to Hamlin's initial care was the use of CPR and the presence of a defibrillator, which allowed medical professionals to act quickly to restore Hamlin's heartbeat. In one Sports Health study, the survival rate for commotio cordis stood at about 25% if the patient received CPR within three minutes of the injury. Survival dropped to just 3% in cases where CPR took more than three minutes to begin.
The challenge for people who suffer this injury is not necessarily an ongoing heart problem after CPR has been performed. The issue may come down to the extent of damage caused by oxygen deprivation to other organs resulting from cardiac arrest.
"When someone has had cardiac arrest, it can decrease blood flow to organs, especially the brain, so we're not really going to know the status of (Hamlin's) condition for a long time to come," Mathew said. "This can take time for his body and his brain and his heart to respond."
More broadly, the U.S. survival rate for cardiac arrest cases suffered outside of hospital settings is as low as 12%, according to the American Heart Association. Timely use of CPR can double or triple the chances of survival.
Dr. Marc Cohen, chairman of the Department of Medicine at Newark-Beth Israel Medical Center, underscored the rarity of commotio cordis in an interview with the New York Post.
"That hit (on Hamlin) had to occur at a certain point in time that was only five milliseconds long," Cohen said. "If that hit occurred one millisecond after or before, this may not have happened."
Although the effects of commotio cordis often appear instantaneously, Cohen suggested other factors could be involved in the physical response displayed by Hamlin, who does not have any other disclosed, pre-existing heart condition.
"More likely than not, what happened is he got up and his rhythm became chaotic. That may have taken a few seconds to occur," Cohen said, adding that adrenaline may have contributed to the onset of ventricular fibrillation.
Pronger, who played the final three seasons of his NHL career in Philadelphia, said he was glad that "Monday Night Football" did not resume after Hamlin's injury.
"They had to call the game Monday night. It was their only choice," Pronger told the Calgary Herald. "Clearly, they made the right call."