As a critical care doctor who sees dozens of patients following cardiac arrest every year, this is about as good of an outcome as can be reasonably expected. Based on the publicly available information, I figure he would be at least in the top 10%, if not the top 5% of outcomes I’ve seen in my career. I was so relieved when they said he was awake and writing.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Nice explanation! Just curious, in non-contact ACL tears, is the process any different? When I was a freshman in college, my team had something like 8 ACL tears over the course of the season, and 1 in particular was an offensive lineman who just came out of his stance and didn’t contact anyone on the play. At the time, some of my teammates blamed all the injuries on the coaches having too many full-contact practices because they thought it would make us tougher.