Submitted by ShepherdsDoof t3_102e4n7 in sports
CodeBlue614 t1_j2uohdl wrote
Reply to comment by waltwhitman83 in Family Statement for Damar Hamlin by ShepherdsDoof
ICU doctor here.
The decision about therapeutic hypothermia (cooling) is made based on the initial neuro exam. Typically, if they’re not following commands, you do it. There’s some debate about whether it’s helpful to actually cool them (target a central body temperature of 32-34 C) vs just preventing fevers (hold central body temp at 36 C). The deeper cooling can cause a lot of metabolic problems, and needs deep sedation and sometimes a paralytic (if they shiver uncontrollably). At my hospital, most patients get 36 C these days. It may be different at UC, I can’t comment on their practice patterns.
Prior to all of the cooling studies, the prognosis was based on the initial exam and the exam between 72-96 hours (3-4 days in). In short, if you’re awake and following commands by then, good sign you’ll be at least semi-independent (for self care) at 6 months. Obviously, if the patient improves in less time, that’s great. Cooling pushes the timeline back. I have had patients wake up and start following commands during cooling, in which case we stop.
During this time, Mr. Hamlin will be reassessed frequently, looking at things like cranial nerve reflexes (from nerves that come directly off the brain and not the spinal cord). These include nerves that control the pupils reacting to light, eye movements, cough and gag reflexes, and blinking. If they are impaired, that’s a bad sign, as they tend to be more resilient than the “higher function” areas of the brain.
As the updates come in during the coming days, look for reports about wakefulness and following commands. If he is off the ventilator at some point this week, he would need to be awake and following commands, so that is a good proxy. If he’s out of ICU in the next 7-10 days, he would need to be off the ventilator.
I’m happy to answer questions if you have them.
waltwhitman83 t1_j2uwbm3 wrote
we have no clue
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his preliminary CT scan results
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if he's had an MRI yet while intubated (unlikely)
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if he's being cooled or not
correct?
if there aren't reports that he's awake and off the ventilator within the next 7-10 days, is he most likely going to be a vegetable/dead or is there some kind of "healing" that could happen while he's in a coma for, 14, 21, 30+ days?
CodeBlue614 t1_j2uzoz0 wrote
The preliminary CT if the head is really only good for looking for bleeding or massive stroke. The changes you see from anoxic injury don’t show up for a while. The neuro exam is actually you’re best tool (better than MRI, if you can believe it), so those assessments will be ongoing. MRI may occur in the next few days, I usually wait until we’re 3-4 days in and the exam hasn’t improved to see if there’s a correlation on imaging.
You’re correct that we don’t know if he’s being cooled or not. He is probably receiving some sort of temperature control therapy, but at some hospitals that may be 36 C (that’s what we do at my hospital) and other may still use 32-34 C. It’s not clear that the lower temperature is better, and it causes some weird things to happen metabolically. I don’t know what they do at UC, since I’m not there.
If he shows no significant neurologic improvement in 7-10 days, it’s very likely that he has severe brain damage, likely irreversible. That could include a vegetative state. He could progress to brain death. The cases where you see someone wake up several weeks later are head traumas. There’s a lot of swelling pushing on the brain cells, but the cells themselves don’t have irreversible damage. In this case, brain cells die from lack of oxygen delivery while the heart isn’t beating. I’m not aware of any anoxic injuries that wake up that far down the road.
waltwhitman83 t1_j2v1b16 wrote
so he went into the tackle, had trauma into his chest area, heart stopped due to the timing of the hit
we had enough blood/oxygen for like 10 seconds to stand up/move
goes down
sideline medical crew rushes over
check him for concussion/spinal injury
how many minutes between going down and getting treatment was his brain starved from oxygen
if it was more than 5 minutes, is he most likely doomed?
CodeBlue614 t1_j2v360r wrote
Usually, we think of 3 minutes as being when damage starts to occur. I believe I read that his pulseless time was around 8 minutes. I have seen people recover nicely from 10 or even 15 minutes of down time, but that isn’t guaranteed. Once you’re around 20 minutes, the outcomes start to look bad. It’s possible to support someone with ECMO during a prolonged cardiac arrest and still have decent outcomes.
In his favor, he’s young and in good physical condition. His heart was in great shape prior to the arrest, so hopefully it isn’t stunned too badly and is able to pump blood effectively. He likely has healthy blood vessels that feed his brain. He did receive medical attention quickly. The tricky thing is that these are just so unpredictable. I’ve seen them go better than expected and worse.
waltwhitman83 t1_j2v3xw3 wrote
thank you very much
i really appreciate you
remindme! 2 days follow up with this nice doctor
CodeBlue614 t1_j33koxl wrote
I heard that Mr. Hamlin is awake and communicating in writing, but still on the ventilator. So neurologically, that is a massive improvement and gives me a lot of reassurance about how his brain is doing. The ventilator is there to help his lungs recover at this point, but I expect continued improvement there in the next few days.
waltwhitman83 t1_j34p6h7 wrote
when do you expect the ventilator will come out/why is he still on it if they let the sedation wear off?
they must have known before hand how he'd react based on what they saw from CT scan or something?
CodeBlue614 t1_j34zibf wrote
There was a report that he had been pronated (turned face down) during the first 24 hours. We really only do that when patients have severe respiratory failure needing high ventilator settings. In this case, it is common to have saliva, vomit, or refluxed stomach acid go into the lungs during CPR, which we call an aspiration event. It is also common to have lungs contusions (essentially bruises) from CPR. Either could cause him to need high ventilator settings early on.
The decision to pronate (flip the patient face down) is based on the ratio between oxygen level in the blood stream to amount supplied by the ventilator (the atmosphere is 21% oxygen, ventilators are usually set between 30-100%). These patients also get chest x-rays using a special portable device, and that x-ray combined with the ratio I mentioned can give you a pretty good idea of how bad things are, even without the CT scan. The problem with the CT scan is you have to leave the ICU on a portable ventilator to get it, so there’s some risk involved if the patient is unstable. I will often delay CT scans if I think they’re too risky for the info I expect to receive.
Without knowing his current ventilator settings, it’s hard to know how much longer until he comes off. He’s probably on little to no sedation currently, since he’s writing. Believe it or not, patients tolerate the ventilator with very little sedation much of the time (sometimes none). Typically we don’t keep sedation that light if the ventilator settings are really high, because there’s so little room for error if the patient and ventilator stop being synchronized. I expect he will get the opportunity to show he’s ready to come off the ventilator every morning going forward, and they’ll take him off when he can past those tests.
waltwhitman83 t1_j35b9r1 wrote
what tests does he need to perform/pass in the morning(s) before being taken off ventilatior? understood that putting it back in, not easy
CodeBlue614 t1_j35ors4 wrote
First step is just being on low enough ventilator settings. I usually want to see the oxygen no higher than 40%, because that is similar to what a regular nasal cannula can do. Second is waking up and following commands when the sedation is turned down or off, which he’s already doing. Third is called a spontaneous breathing trial. The ventilator mode is changed so that the patient has more control, and we see how they do with minimal support. Usually, that lasts for 30 minutes, but we might do 1-2 hours if we’re worried about how things are going to go. If the patient’s breathing becomes rapid and shallow, they aren’t ready. Finally, we check a cuff leak. The breathing tube has a balloon shaped like a donut called a cuff that forms a seal against the trachea. We deflate the cuff and check to see that air can escape around the breathing tube. It’s a way to screen for upper airway swelling.
You certainly don’t want to be taking the tube out and putting it back in repeatedly, but there will be times when it has to go back in. In Damar’s case, he’s young and healthy and it’s only been a few days, so I would expect he does well once it comes out.
waltwhitman83 t1_j36cjfy wrote
how would they know he’d “wake up” and his brain would be ok enough to follow commands instead of letting him sleep 2-5 more days in a coma?
CodeBlue614 t1_j36st7w wrote
There’s no way to know when/if he will wake up at the beginning. Usually we try to use the least sedation possible to keep the patient comfortable (based on non-verbal signs) and in synch with the ventilator. If that can be achieved with a low to medium dose, then the patient can wake up once their brain recovers enough.
If he’s condition had been such that he needed deeper sedation, then sedation would be lightened when those other problems improved.
The brain isn’t going to benefit from the sedatives, especially at high doses. The more time a patient spends on high-dose sedation, the more confused they get. Sedation is dosed at “just enough to get the job done”. The nurses have protocols for adjusting sedation doses based on what’s going on.
If you every hear of someone being in a medically-induced coma, think of it as a necessary evil to help facilitate other therapies to support one or more failing organ systems, rather than a therapy in and of itself. There are rare instances when the sedation is the therapy (e.g. continuous seizures that we can’t break), but usually it’s there to facilitate other therapies.
waltwhitman83 t1_j2uwgi2 wrote
> During this time, Mr. Hamlin will be reassessed frequently, looking at things like cranial nerve reflexes (from nerves that come directly off the brain and not the spinal cord). These include nerves that control the pupils reacting to light, eye movements, cough and gag reflexes, and blinking. If they are impaired, that’s a bad sign, as they tend to be more resilient than the “higher function” areas of the brain.
it seems highly unlikely that they'll release this information to the press/media/fans, despite the fact that basically millions of people will most likely look at football differently if a player dies from a routine tackle, no?
Ajax444 t1_j2uyc8x wrote
I don’t think people will look at football differently. I have seen 2 basketball players die on the court, and heard about the Price brothers (Mark and Brent-ex NBA players) father collapsing after a pick-up game, and Pete Maravich.
A soccer player recently had cardiac arrest on the field (last year?). I remember the Detroit Lions player that got paralyzed on the field. These sports go on, and these instances are soon out of sight/out of mind.
I mean, the UFC has 2 barely protected people in the ring looking to concuss their opponent. It’s not going anywhere soon.
These gentlemen (and ladies) know the potential consequences, and choose to participate. While it may not he in their best interest, physically and mentally, it is their right to make that decision.
CodeBlue614 t1_j2v0cn2 wrote
I doubt we’ll hear those smaller details. I added that part to help people understand the process a little better. I’d expect a bigger picture, more general update once a day. If he wakes up, I would imagine that’s a story that warrants an urgent update by sports outlets, and it would definitely be cause for relief.
waltwhitman83 t1_j2v1fgz wrote
if we don’t hear that he’s awake in 2 more days, would you say it’s most likely bad?
is there any way they could’ve already woken him up if they saw all positives?
CodeBlue614 t1_j2v44st wrote
In a few cases, I’ve had people wake up during CPR. That’s rare. Waking up within the first few hours does happen, and those people tend to do well. The longer he goes without waking up, the more worried I get. When we get to 7-10 days, it’s pretty clear that things aren’t going to go well. Additionally, if I see cranial nerve reflexes that are absent or sluggish, or new seizures, I know things are going badly. If he’s 2 days in, not awake yet, but his reflexes are all normal, he can still have a good recovery.
I know these are long answers, but this stuff is complicated.
waltwhitman83 t1_j2v4lid wrote
will they be testing his reflexes if he’s sedated on purpose/being cooled?
CodeBlue614 t1_j2wnq05 wrote
It depends on the depth of sedation. In most patients, we’re aiming to keep a patient calm, but awake, or at most drowsy. If they made the decision for cooling to 32-34 C, he would be more deeply sedated. You can still check reflexes under those circumstances. If they had to use a paralytic to control shivering, then most of those reflexes won’t be there. The pupils will still react to light, so those are still checked. When we do temperature control at 36 C, I keep sedation pretty light, because there tends to be a lot less shivering, and I can greatly reduce the amount of drugs the patient is exposed to.
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