Damar Hamlin is headed home to Buffalo!

Groovenstein

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As for trying to settle the game in an unconventional way that would raise money for him and his family while not psychologically breaking these guys any further: I’m sorry the concept so deeply offended you that you had to post to express your displeasure, shortly after telling me not to post nonsense.
Mate, you had the idea to use a game of Madden not as a fundraiser or a means to accomplish some positive change, but as a way to resolve an actual NFL football game. Fair enough, I’m sure we’ve all had plenty of unconventional ideas. But then you loosed this idea from the confines of your brain to a public message board. What sort of response did you think you would get?
 

Fred in Lynn

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CNN had Gupta and Reiner on late in the 7:00 hour again after the interview with his uncle and they suggested he’s not close to being out of the woods. They believe he is prone to avoid clotting in his lungs, and suggested he could have damage that occurred to organs other than his heart, including his brain (they stressed it’s hard to know because they’re not Bill Frist, and don’t know fine details). They also can’t say for sure if it’s entirely due to the hit to his chest or could be related to some undiagnosed congenital issue. He apparently had to be resuscitated a second time at the hospital. A best case scenario is complete recovery, but too soon to say.
 

Valek123

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I do not understand the implications of having to be resuscitated twice after having CPR performed by professionals for 9 minutes (or more) prior and having lung damage be the concern. I am, admittedly, ignorant about the process though.

Good quality compressions and early defibrillation could lead to clear recovery with the only issue being a displaced rib fx?

Good compressions are often rough on the rib cage and fractures are exceedingly common(I believe almost 75%), lung damage can follow as circle bones often break in multiple places and are sharp. However no one is upset about broken ribs though sitting in a hospital bed recovering.


I am not disagreeing. It is a basic skill that has been continually simplified (with better outcomes).

What I wonder is if Joe Doe will actually do the compressions needed. Not that they dont want to, but cracking a sternum is kinda difficult. (Oh lord the med shows when they are bending elbows for compressions. )

I agree everyone should know cpr. But i wonder if compressions on a cpr dummy add up to actual compressions.

aeds are awesome, but there are what 2 shockable rhythyms?


I 110% support everyone getting cpr trained. I just wonder the quality
Much of the “better outcomes” from what I have read is based upon Joe Dirt actually doing it because of the simplification. One of the most successful programs I’ve heard about is in, of all place’s(given this event), Cincinnati.

We have had resuscitations started by bystanders who took a CPR course, and had a life returned. I’ve done CPR on a person in an unshockable rhythm only to have the rhythm convert and deliver a shock. Unshockable now does not always translate to unshockable forever, good compressions buys time for ALS arrival with other options to impact surviveability.

The biggest advice I can give is keep pushing on the chest and allow it to fully rebound. Allowing the chest to fully rebound and not “lean” on the chest allows good veinous return to the heart from the brain allowing oxygen rich arterial blood to return and keep the most important organ oxygenated to allow full recovery potential. Hollywood has trained a global market how to do poor quality t-Rex elbow bend cpr.

59661

If it can be done in rural New England with 25-30 minute trips via ambulance to the hospital, outcomes can be dramatically improved in cities.

The poster child for this is King County in Washington state, they consistently score extremely high in recovery percentages.
Early call to efficient 911 systems, with good bystander cpr, to high compression fraction BLS to fast ALS response is the golden ticket. However in nearly 100% of the cases if the first parts of 911 notification and compression are not started is death. Push the chest save a life.
 

AlNipper49

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Being on a vent can damage your lungs, too.
Ah, I did not know that. But in a weird sort of way that also reconfirms my questions. Like just 24 hours ago the question was if he would live. Now judging by the tweet the biggest question (going just by the tweet, I understand that it may be more complex) would be how much the consequence of saving him (lung damage) would be. Going in, wouldn't they just assume that perhaps there would be lung damage? Obviously having a damaged set of lungs is better than being dead. And if he's still recovering from basically being dead for a bit then why does the lung thing shoot up so quickly?

There is a nuance that I'm missing that may be as simple as assuming that lung damage would be "in addition to" that perhaps was inferred in that tweet.
 

RobertS975

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Jul 28, 2005
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The ambulance timing was unimportant here. Assuming that the young man received high quality CPR and
I do not understand the implications of having to be resuscitated twice after having CPR performed by professionals for 9 minutes (or more) prior and having lung damage be the concern. I am, admittedly, ignorant about the process though.
MD here... the implication of a second episode of v. Fibrillation is that there might be some underlying cause of the arythmia aside from the blunt trauma and commotio cordis. Hypertrophic cardiomyopathy etc. But a heart that has experienced ventricular fibrillation and been shocked back to sinus rhcan still have a propensity to revert back toventricular fibrillation or tachycardia. Antiarythmic drugs usually are given to fight that irritability.
 

Jeff Frye's Face Mask

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A second location.
CNN had Gupta and Reiner on late in the 7:00 hour again after the interview with his uncle and they suggested he’s not close to being out of the woods. They believe he is prone to avoid clotting in his lungs, and suggested he could have damage that occurred to organs other than his heart, including his brain (they stressed it’s hard to know because they’re not Bill Frist, and don’t know fine details). They also can’t say for sure if it’s entirely due to the hit to his chest or could be related to some undiagnosed congenital issue. He apparently had to be resuscitated a second time at the hospital. A best case scenario is complete recovery, but too soon to say.
If his care team has placed him in a prone position while on the ventilator, it is most likely due to the fact that he has significant issues with oxygenation. Prone positioning does not have any effects on clotting. That is, the ability for oxygen to enter his body via his lungs is significantly impaired due to damage in his lungs. What that damage is from is difficult to say at this point without knowing the full details but most commonly in these circumstances, it is due to one of two things (both of which can occur at the same time). The first is a marked amount of fluid build-up in the lungs due to a failing/injured heart. When the heart cannot beat efficiently (notably the left side of the heart), fluid backs up into the pulmonary vasculature and then spills into the lung tissue itself. The second is aspiration. During a resuscitation, it is not uncommon for patients to aspirate gastric secretions/vomit into their airway and lungs. This can kick of a storm of inflammation in the lungs as well as even a pneumonia and subsequently compromise oxygenation. Overall, if the lung injury is severe enough, resulting effects can cause other organ systems to be injured/fail (notably the kidneys).

Ventilator management of patients with these types of issues can be tricky but any potential harm delivered by the ventilator (and appropriate settings by an experienced care team can minimize this harm) is far outweighed by the benefit provided by the ventilator (getting oxygen in and carbon dioxide out).

It is unlikely that his current lung issue is driven by any form of pneumothorax (hole punctured in the lung) as that is (usually) easily solved with a (or a few) chest tubes and if you subsequently have a pneumothorax with chest tubes in place, we really do not then put you into prone positioning.

It's not uncommon for folks who have a cardiac arrest and are resuscitated to then have another arrest given all of the damage that the body subsequently gets exposed to as a result of the initial arrest and lack of perfusion. As an example, high levels of acid can build up which can predispose to another arrest as can recurrent abnormal heart rhythms.

At this point, based on everything that has been shared in this thread (and it's really the only place I've been looking at for updates so I apologize if I have missed something), Damar would appear to have multiorgan system dysfunction/failure (CNS, Cardiac, Pulmonary). This is a difficult position to be in.

EDIT - Nice pull on the CRALE paper @AlNipper49 ! We kick that around with our learners.

2nd EDIT - Spelling
 

Preacher

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See my post above... but you're correct that it's about 50% that need it actually get it.

About 4% survive if they need CPR and don't get it vs 10-15% survive if you need CPR and do get it.
Based on what you posted, it seemed like they did get CPR when EMS arrived. So they got CPR but got it much later than immediately (or as soon as possible). Still, like 3-4x higher survival rate with CPR as soon as possible as opposed to at arrival of EMS.
 

McBride11

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Good quality compressions and early defibrillation could lead to clear recovery with the only issue being a displaced rib fx?

Good compressions are often rough on the rib cage and fractures are exceedingly common(I believe almost 75%), lung damage can follow as circle bones often break in multiple places and are sharp. However no one is upset about broken ribs though sitting in a hospital bed recovering.




Much of the “better outcomes” from what I have read is based upon Joe Dirt actually doing it because of the simplification. One of the most successful programs I’ve heard about is in, of all place’s(given this event), Cincinnati.

We have had resuscitations started by bystanders who took a CPR course, and had a life returned. I’ve done CPR on a person in an unshockable rhythm only to have the rhythm convert and deliver a shock. Unshockable now does not always translate to unshockable forever, good compressions buys time for ALS arrival with other options to impact surviveability.

The biggest advice I can give is keep pushing on the chest and allow it to fully rebound. Allowing the chest to fully rebound and not “lean” on the chest allows good veinous return to the heart from the brain allowing oxygen rich arterial blood to return and keep the most important organ oxygenated to allow full recovery potential. Hollywood has trained a global market how to do poor quality t-Rex elbow bend cpr.

View attachment 59661

If it can be done in rural New England with 25-30 minute trips via ambulance to the hospital, outcomes can be dramatically improved in cities.

The poster child for this is King County in Washington state, they consistently score extremely high in recovery percentages.
Early call to efficient 911 systems, with good bystander cpr, to high compression fraction BLS to fast ALS response is the golden ticket. However in nearly 100% of the cases if the first parts of 911 notification and compression are not started is death. Push the chest save a life.
You are correct. I was just rambling mostly, it was musings. Even imperfect cpr is better than none. Thank you
 

Mystic Merlin

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If his care team has placed him in a prone position while on the ventilator, it is most likely due to the fact that he has significant issues with oxygenation. Prone positioning does not have any effects on clotting. That is, the ability for oxygen to enter his body via his lungs is significantly impaired due to damage in his lungs. What that damage is from is difficult to say at this point without knowing the full details but most commonly in these circumstances, it is due to one of two things (both of which can occur at the same time). The first is a marked amount of fluid build-up in the lungs due to a failing/injured heart. When the heart cannot beat efficiently (notably the left side of the heart), fluid backs up into the pulmonary vasculature and then spills into the lung tissue itself. The second is aspiration. During a resuscitation, it is not uncommon for patients to aspirate gastric secretions/vomit into their airway and lungs. This can kick of a storm of inflammation in the lungs as well as even a pneumonia and subsequently compromise oxygenation. Overall, if the lung injury is severe enough, resulting effects can cause other organ systems to be injured/fail (notably the kidneys).

Ventilator management of patients with these types of issues can be tricky but any potential harm delivered by the ventilator (and appropriate settings by an experienced care team can minimize this harm) is far outweighed by the benefit provided by the ventilator (getting oxygen in and carbon dioxide out).

It is unlikely that his current lung issue is driven by any form of pneumothorax (hole punctured in the lung) as that is (usually) easily solved with a (or a few) chest tubes and if you subsequently have a pneumothorax with chest tubes in place, we really do not then put you into prone positioning.

It's not uncommon for folks who have a cardiac arrest and are resuscitated to then have another arrest given all of the damage that the body subsequently gets exposed to as a result of the initial arrest and lack of perfusion. As an example, high levels of acid can build up which can predispose to another arrest as can recurrent abnormal heart rhythms.

At this point, based on everything that has been shared in this thread (and it's really the only place I've been looking at for updates so I apologize if I have missed something), Damar would appear to have multiorgan system dysfunction/failure (CNS, Cardiac, Pulmonary). This is a difficult position to be in.

EDIT - Nice pull on the CRALE paper @AlNipper49 ! We kick that around with our learners.

2nd EDIT - Spelling
Well, fuck, this doesn’t sound good.

Being a layperson sucks in situations like this, I feel taken for a ride by how his condition/prognosis happens to be framed in media reports from people who are not providers.

Really makes me appreciate all the detailed, direct information being provided by actual experts in this thread.
 

chechusma

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The ambulance timing was unimportant here. Assuming that the young man received high quality CPR and

MD here... the implication of a second episode of v. Fibrillation is that there might be some underlying cause of the arythmia aside from the blunt trauma and commotio cordis. Hypertrophic cardiomyopathy etc. But a heart that has experienced ventricular fibrillation and been shocked back to sinus rhcan still have a propensity to revert back toventricular fibrillation or tachycardia. Antiarythmic drugs usually are given to fight that irritability.
I agree - a second arrest would substantially widen the confidence intervals on our collective hypothesis about the cause of the initial arrest, as you note. It shouldn’t happen with a young, otherwise healthy heart with a short down time (who presumably didn’t get a ton of epinephrine etc) due to commotion cordis (more of a “one off” thing).

so if it did happen, I would be thinking more along the lines of the congenital stuff (HOCM/IHSS, long QT, Brugada, etc) or alternatively, caused by the resuscitation (something like a tension pneumothorax from chest compressions, or even stuff like an intubation attempt gone wrong.

I would really like to see more details/confirmation because commotio cordis really seemed to fit the picture in a way that nothing else really seems to.

(I will also note that the info about a lung injury and him being able to be weaned down to 50% oxygen from 100%. This is something that I would have expected they would have been able to do fairly rapidly in an otherwise uncomplicated arrest, and the fact that they didn’t (at Cincinnati no less - which was the site of the first residency training program in emergency medicine - and are leaders in resuscitation) suggests there is more to the story. )
 

Jeff Frye's Face Mask

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A second location.
(I will also note that the info about a lung injury and him being able to be weaned down to 50% oxygen from 100%. This is something that I would have expected they would have been able to do fairly rapidly in an otherwise uncomplicated arrest, and the fact that they didn’t (at Cincinnati no less - which was the site of the first residency training program in emergency medicine - and are leaders in resuscitation) suggests there is more to the story. )
My exact thoughts as well. Hearing about the prone positioning was surprising. Usually do not have to get into that area with an uncomplicated arrest.
 

Deathofthebambino

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Hamlin's fundraiser now over 5.6 million.

Tom Brady and Russell Wilson chime in with 10k each, and Matt Stafford tops them at 12k. Chris Jericho made two different 5k donations.\

Kind of cool stuff to see.
 

Marciano490

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When people say lung damage - what does that mean exactly? Bruising/scar tissue from compressions/broken ribs of some sort of loss of functionality while Hamlin’s system was shut down?
 

Laser Show

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When people say lung damage - what does that mean exactly? Bruising/scar tissue from compressions/broken ribs of some sort of loss of functionality while Hamlin’s system was shut down?
Could mean a lot of things, trauma secondary to CPR (broken ribs, hemopneumothorax, pulmonary contusions) or trauma secondary to the arrest itself (pulmonary embolism/infarction, aspiration).
 

AlNipper49

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Hamlin's fundraiser now over 5.6 million.

Tom Brady and Russell Wilson chime in with 10k each, and Matt Stafford tops them at 12k. Chris Jericho made two different 5k donations.\

Kind of cool stuff to see.
It was also cool that Andy Dalton threw a few grand into the pool. The Bills mafia threw a bunch into his charity, somewhat ironically, after he helped them to a victory last season.
 

BigSoxFan

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Honestly, some of this money needs to go to him, if he is fortunate enough to survive this. The health expenses could be extensive although perhaps the NFL helps out there in some way.
 

StanleySteamer

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I am late to the party so I apologize for any repetitive info (I was working last night and did not see the hit in real time). FWIW, I agree with most of the experts that commotio cordis is the initial insult leading to an unstable ventricular arrhythmia requiring defibrillation. Not much else makes sense. There are really no mechanical events (cardiac rupture, aortic dissection, cardiac tamponade) that are corrected by CPR and defibrillation alone even in the short term - particularly one that causes sudden collapse. A preexisting cardiac condition such as hypertrophic cardiomyopathy, long QT syndrome, and Brugada seems unlikely because, by the time athletes get to this stage, they have been screened multiple times in the post Gathers/Lewis era. Most D1 athletes have had EKGs and echocardiograms before they step on the field (one of my partners is an MD for a D1 college BB program). Even many competitive HS programs

Many people have asked why we don't see this in football more often. I remember a colleague of mine who was at Tufts at the time did some research on this in the 90's. There is a very small portion of the cardiac cycle - maybe 10ms or less, where the heart muscle cells have depolarized and caused the muscle to contract, and are in the process of repolarizing, where blunt trauma can lead to a fatal arrhythmia. Commotio has been documented most often baseball. His theory was that most of the time it occurred when a baseball struck a stationary player in the chest - stationary, where their resting HR may be lower, as opposed to a DB who just ran flat out for 30 yards. Higher HR = less time in the "vulnerable zone." Explains why we may not see this often in FB, but I am sure we will be an increased awareness of this condition in the coming days.

Another factor may be electrolyte abnormalities - depending on the player's state of hydration, at any point during a professional sporting event Damar may have had a number of metabolic abnormalities (Low potassium, magnesium, and calcium) which could predispose to arrhythmias - not likely to be a primary cause, but possible contributors to a perfect storm.

I am worried about the reports that only by today oxygen is weaned down to 50%, they are employing prone ventilation, etc. This suggests a second insult, possibly as a result of the resuscitation. I would not expect a young healthy patient who received 9 minutes of quality CPR to be at high risk for anoxic brain injury. However, I think 9 minutes for the application of an AED with the resources on hand is an excessive length of time.

Sorry for stream of consciousness post, but I wanted to put my two cents as a cardiologist in.
 

E5 Yaz

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Honestly, some of this money needs to go to him, if he is fortunate enough to survive this. The health expenses could be extensive although perhaps the NFL helps out there in some way.
This was a small charity he set up with a modest goal. I hope there are people involved with administering it who do right by the charity as well as his needs.
 

Ed Hillel

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Honestly, some of this money needs to go to him, if he is fortunate enough to survive this. The health expenses could be extensive although perhaps the NFL helps out there in some way.
They don't get health insurance as part of the newly negotiated CBA?
 

BigSoxFan

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This was a small charity he set up with a modest goal. I hope there are people involved with administering it who do right by the charity as well as his needs.
Yup. I’m a CFO for a large nonprofit and I can almost assure you they’re not set up for this kind of windfall. Hope this can be the seed money for a long lasting, more sophisticated operation.
 

Kliq

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It was also cool that Andy Dalton threw a few grand into the pool. The Bills mafia threw a bunch into his charity, somewhat ironically, after he helped them to a victory last season.
Yes, Dalton threw a late-game TD when he was with Cincinnati to beat Baltimore in Week 17 that helped the Bills get to the playoffs for the first time in 18 years, and Bills fans donated almost $500,000 to Dalton's foundation.

https://www.espn.com/nfl/story/_/id/24394817/andy-dalton-wife-thank-bills-fans-charity-money-donating-buffalo-hospital
 

radsoxfan

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I would not expect a young healthy patient who received 9 minutes of quality CPR to be at high risk for anoxic brain injury. However, I think 9 minutes for the application of an AED with the resources on hand is an excessive length of time.

Sorry for stream of consciousness post, but I wanted to put my two cents as a cardiologist in.
Was it reported that it took 9 minutes to apply an AED? Agreed that would be really bad given the number of medical personnel on site and presumably easy access to an AED.

In hospital early defibrillation for cardiac arrest is usually within a minute. Even for out of hospital cardiac arrests, 3-5 minutes is considered fast but often achievable. No idea how it could have taken them 9 minutes to get it set up, hope that’s not the case.

As far as 9 minutes without a pulse, even with good quality CPR, that would still make me pretty nervous for brain injury….
 

bsj

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Well, fuck, this doesn’t sound good.

Being a layperson sucks in situations like this, I feel taken for a ride by how his condition/prognosis happens to be framed in media reports from people who are not providers.

Really makes me appreciate all the detailed, direct information being provided by actual experts in this thread.
100% agree. The small nuggets of info that are leaked without context make it impossible to have any real idea what is going on.
 

wade boggs chicken dinner

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Want to echo the thanks to all of the medical experts posting their thoughts. Best information on the internet. Really appreciate sharing all of the knowledge.
 

Marciano490

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Are they unable to monitor brain functionality at this point or is it just not a priority?
 

AB in DC

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Washington Post has a little more detail about the lhe league's communications last night.


Shortly after the ambulance left the field, Buck told viewers that the game would restart after a five-minute warm-up period, based on information that had come from ESPN officiating analyst John Parry, according to a person with knowledge of the broadcast. During every Monday night game, Parry corresponds with the league’s officiating department about issues such as replay review decisions, then relays information to Buck and his analyst, Troy Aikman. But this decision had escalated beyond those with whom Parry typically communicates.

“They’re going to try to continue to play this game,” Buck said at 9:13 p.m.
More here:
https://www.washingtonpost.com/sports/2023/01/03/damar-hamlin-nfl-emergency-action-plan/
 

bsj

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This whole thread, this whole episode, has given me flashbacks to my mom's dying.

She suffered a heart attack while walking the family dog and was found an estimated 12-14 minutes after it happened. They worked to resuscitate her as quickly as they could, but she never regained any semblance of consciounsess. We ended up having to turn the machines off 2 days later.

She was older, and less fit, and the time was longer, but this is still giving me flashbacks.

Note- not trying to be the center of attention, just saying it's a context I have. I really really hope Demar's family has more options.
 

Jody Reed's 1988 Mustache

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Are they unable to monitor brain functionality at this point or is it just not a priority?
If the reports of prone ventilation are true, then probably not a priority yet. Besides, once he’s flipped back supine, a good neurological exam off of sedation is the best way to monitor brain function.

Typically, once these patients are medically stable, if they haven’t shown much in terms of regaining consciousness, we would get an MRI for ‘prognostic purposes’, i.e. is there a massive stroke that makes it unlikely this person will ever wake up. That is of course unknowable and an MRI will never be able to tell you that for sure but it can give you a sense of the likelihood at least. This is mostly from taking care of neurocritical care patients 10 years or so ago though so someone on the board may have more updated practice patterns.
 

djbayko

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Honestly, some of this money needs to go to him, if he is fortunate enough to survive this. The health expenses could be extensive although perhaps the NFL helps out there in some way.
Can they do that (both legally and in accordance with GoFundMe rules) - set up a page for charity A but then use it for something else? I doubt any of the recent donors would mind at all, but I’ve been wondering about the implications of everyone donating to this mega million dollar toy drive.
 

teddywingman

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Apologies if I missed it, but could we have a member here give a CPR breakdown?

I took a class 25 years ago to obtain a guide license, and I did some google the other night, but honestly I think a summation here might be best.
 

JimD

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This whole thread, this whole episode, has given me flashbacks to my mom's dying.

She suffered a heart attack while walking the family dog and was found an estimated 12-14 minutes after it happened. They worked to resuscitate her as quickly as they could, but she never regained any semblance of consciounsess. We ended up having to turn the machines off 2 days later.

She was older, and less fit, and the time was longer, but this is still giving me flashbacks.

Note- not trying to be the center of attention, just saying it's a context I have. I really really hope Demar's family has more options.
No need to apologize. I lost my dad to pancreatic cancer over 30 years ago, and any time I hear of a person diagnosed with or losing their life to this awful disease it brings me right back to those dark days. I hope writing that post helped you in a way.
 

Valek123

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.
Apologies if I missed it, but could we have a member here give a CPR breakdown?

I took a class 25 years ago to obtain a guide license, and I did some google the other night, but honestly I think a summation here might be best.
Decent training video on hands only cpr

AHA hands only 2 min video

Full AHA BLS certification

Call 911! Let the chest rebound, use your core not arms to push, 100-120 compressions a minute. Use other people if available, you will get Tired quicker than you would expect. You end up looking like you played pickup basketball after 5 minutes of CPR. Hard and Fast until help arrives.
 

CPT Neuron

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Are they unable to monitor brain functionality at this point or is it just not a priority?
As long as he remains "cooled" and sedated, his neurologic status is low on the priority list.


If the reports of prone ventilation are true, then probably not a priority yet. Besides, once he’s flipped back supine, a good neurological exam off of sedation is the best way to monitor brain function.

Typically, once these patients are medically stable, if they haven’t shown much in terms of regaining consciousness, we would get an MRI for ‘prognostic purposes’, i.e. is there a massive stroke that makes it unlikely this person will ever wake up. That is of course unknowable and an MRI will never be able to tell you that for sure but it can give you a sense of the likelihood at least. This is mostly from taking care of neurocritical care patients 10 years or so ago though so someone on the board may have more updated practice patterns.
Warm him, lighten his sedation, and get a good Neurologic Examination. There are key exam findings at key points in the time line that help with prognostication. For example, pupillary response in the first 24 hours is the primary exam finding we look for. After that, it is things like motor response, eye movements, spontaneous eye opening, following commands, etc., as well as the rest of the exam, that we use. There are key time points, first 24 hrs, day 1, day 3, 1 week, that we perform these exams to get a better idea of recovery potential. Imaging is helpful, but more adjunctive compared to a good exam in my experience (but I'm old and still value a good, old fashioned neurologic exam as an artistic expression of science).
 

Cellar-Door

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https://theathletic.com/4055531/2023/01/04/damar-hamlin-nfl-emergency-plan/

For those with the Athletic, this is an interesting overview of the NFL's emergency plan, it is extensive, and involves things like multiple mandatory rehersals, mandatory meetings between all the medical personnel before each game to assign roles and review equipment and exit routes. It also goes into all the CBA required personnel (and required credentials) that have to be on site as well as dictating the presence of 2 EMT crews and ambulances, which must be advanced life support ambulances.

There are many ways that the NFL doesn't really give a shit about player safety, but I have to say their emergency procedures are really thorough.