Damar, Bronny and the Meaning of Heart
If you’re a sports fan, you remember where you were on January 2, 2023, when Damar Hamlin of the Buffalo Bills collapsed on the field after making a tackle during a key Monday Night Football game. I was in my car, watching the game on my phone (disclaimer: my wife was driving). Almost immediately, my good friend and former colleague, Jeff Dayton, a huge Bills fan, texted me “Commotio cordis?” As Pediatric Cardiologists, the injury appeared classic for the condition – significant blunt force trauma to the center of the chest – even though it is more typically seen in teens and tweens than adults, and way more common in baseball and softball than in football. We both were struck by seeing it happen live, but once we saw it we marveled that it doesn’t happen more frequently in that sport.
Obviously the first moments were key to Damar’s survival and wellness. He received immediate resuscitation on the field and recovered completely. There is no preceding condition that made him, or makes anyone else, more or less susceptible to commotio cordis than everybody else. It’s just terrible luck, akin to being hit by lightning. The number of deaths in the US is roughly the same for both – about 20 per year.
To us, there didn’t seem any reason why Damar should not be allowed to play football again, if he recovered completely. Indeed a few days later he left the hospital, professing his intention to return to the NFL. He was cleared to play, and returned to action last season. But just because he could return to the field, that does not guarantee that he would. No matter how logical it is to consider the risk to be less than miniscule, it still took a great deal of courage to return to the scene and the circumstance of the catastrophe, to look it in the eye and forge ahead. I admire him for that. Damar Hamlin is an inspiration.
By the way, the day after the incident I dashed off a letter to ESPN – which broadcast the game live – alerting them to the fact that there is a reduced impact baseball that plays much like every other baseball, but reportedly decreases the risk of commotio cordis by as much as 75%. Little League Baseball, Inc., does not support use of the safer ball. I suggested that ESPN might lobby the Little League to reconsider the reduced impact ball. Little League Baseball might heed ESPN’s advice since their income derives largely from the broadcast rights for the Little League World Series. No one wants to consider an ESPn audience seeing the Damar Hamlin incident playing out again, this time involving somebody’s 12 year old child.
The Damar Hamlin incident, it turns out, was not the last brush with sudden cardiac death involving a notable American athlete. On July 24, 2023, Bronny James, son of Lebron, collapsed on the court while working out in advance of starting his college basketball career at USC. That event, and at least part of the moral for this blog, carves a separate identity because it involves one of the world’s most famous athletes, albeit as the father of the victim.
Like most New York sports fans, my distant relationship with Lebron James is....complicated. I’ve followed him since he was in high school. My nephew played in a high school tournament against Lebron’s school, and therefore we were always aware of him. He has been a marvelous player, and has been fixed in the public eye for well over two decades now. Is he the greatest player I’ve ever seen? Pull up a chair and we can discuss, but beyond Michael Jordan, Magic Johnson and Kareem Abdul Jabbar there aren’t too many to discuss. Like the others, Lebron never played for a team I rooted for, and therefore as much as I would like to just sit back and revel in their excellence, I spent the entirely of all of their careers wishing them failure (and largely being disappointed). The same is true of Tom Brady. As a Ravens/Giants fan, I never rooted for Brady once. When all was said and done, I wished I had appreciated his greatness more.
Of course in Lebron’s case, there’s the extenuating circumstance of “The Decision,” the choreographed and televised announcement of his free agent destination in 2010, which deserves its own wing in the Narcissism Hall of Fame. Of course, we hated “The Decision” mostly because the decision was not to play for the Knicks. But while I can forgive that (there are 28 other teams he didn’t come to either) and I can get past the self-centeredness of the whole event (he didn’t force anybody watch it), I can never reconcile the fact that he made the announcement at a Boys and Girls Club that was about 10 minutes away from the Knicks’ practice facility, surrounded by children who one would assume were all or at least mostly all Knicks fans. It was unnecessary, rude and borderline cruel. I’d love ESPN to do a 30-for-30 for the 15th anniversary of the debacle, and interview those kids as young adults. If they weren’t - and aren’t - bothered by it, then I’ll let it slide. But it always left a sour taste in my mouth, and it offered at least a rationalization to root against Lebron, above and beyond team rivalries. One could paint Lebron a villain, and at least pretend that he should be resented because his values were not up to par. We tend to look the other way for the players that we root for, and keep the rivals under a shaded microscope. I've rooted against Lebron for a decade and a half now, and admit that I probably would have done so even if he had handled The Decison correctly.
Back to Bronny, then. He was resuscitated and recovered completely. The recovery of both Damar and Bronny is remarkable, since only about 10% of patients who suffer out-of-hospital cardiac arrest actually survive to hospital discharge, and many of those suffer physical or neurologic damage that would make participation in high level sports impractical. Of course most victims are not so fortunate as to have immediate action by trained personnel, as our high level athletes do. If this had happened on the West4th Street courts, or to some kid shooting hoops in the driveway, or at a sleepaway camp in the Catskills, it may have ended differently.
We don’t really know what happened to Bronny. He and his family, as is their prerogative, have not shared details of his diagnosis other than that he had a “congenital heart defect.” He could have hypertrophic cardiomyopathy (by far the most common cause of sudden cardiac death in the US and everywhere else), or a congenital coronary artery anomaly (#2 in the US, and a real conundrum for Pediatric Cardiologists, since modern imaging identifies more healthy and asymptomatic people with this condition than we ever thought were present before). He could have one of the many arrhythmias that occupy the rest of the list. We would not generally lump those in as “congenital heart defects” but in the lay media it would not be inaccurate to do so. Regardless, it was something bad, and he was really blessed to survive.
It may be that whatever Bronny has, or had, is something that may have been uncovered in advance of his near-death experience using pre-participation screening (mostly, ECG) that is mandated in much of the medically-developed world but not in the US. That’s a subject beyond the scope of this blog (at least for today!)
It’s also very likely that whatever the diagnosis is, the current (and way overdue for revision) recommendations of the American Heart Association would preclude Bronny’s continued participation in competitive sports like basketball. As clinicians we rely on those guidelines as we counsel patients and families with these conditions. These are some of the hardest conversations we ever engage in. When the risks are high, the conversation is easy. But when the risk is remote, or when you realize your patient has a mild form of a condition but the guidelines cut a wide swath, you find yourself trying to negotiate to a gray area that might not actually be there.
I think that may be why there have been nearly 10 years since the last revision of those guidelines, when we usually expect them after 7 or 8. The paradigm shift, I think, will be toward shared decision-making, meaning that patients and families will be empowered to take reasonable risks as they see fit, when the benefit of participation outweighs the concern. One can argue that a chance at a professional career that might net tens of millions of dollars might be on a different level than it would for someone who does not have that potential. This might place a higher burden on athletic programs, leagues, the NCAA, etc., since it will increase the expectation for immediate availability of emergency personnel and equipment, not just at games but also at practices, workouts and any other activities. On the other hand, those capabilities should be available anyway, since we don’t really know for sure which athlete is the next needle in the haystack. So maybe acknowledging an individual’s right to dictate their own risk tolerance may actually liberate the governing bodies from certain risks and responsibilities for all of them.
Regarding Damar’s and particularly Bronny’s return to play, I have a different view of this topic than I might have had at other portions of my life. As a lifelong sports fan, but looking at it through only that lens there’s a roughly 29/30 chance that I would favor an affected athlete being disqualified, since that’s approximately the likelihood that they play for “my” team. Opponents are replaceable. What’s one less? It sounds cold, but fandom is blind, and distant, especially regarding the other guys.
As a physician, I have been trained to take a worse-case-scenario point of view. At least some portion of that stems the fact that we practice in the most litigious medical environment in the world, so no amount of identifiable risk is ever tolerated. The doctrine of shared decision making is anathema to that philosophy but may in effect be a shift toward reason.
But in recent years I have come to view sports from a different angle, which is that of an athlete parent. I played sports as a kid but was never talented enough, or motivated enough, to consider any level past high school, and no sport ever became a part of my self-identity like my academic prowess did. Now I have a son who is a collegiate lacrosse goalie. In him, and his teammates, I see the vital importance of sport, not for the spectator but for the participant. I understand now the deep loss that removal from sport can represent. The decision to clear an athlete or disqualify them is all of a sudden not so cut and dry. There really has to be room for personal choice, within reason.
I’ve never been qualified to see is question through Bronny’s eyes. I’ve spent my adult life looking at it through his physicians’ eyes. But here I am, ironically, trying to look at an important decision through, of all people, Lebron James’ eyes.
So, even though nobody asked me, I would defend Bronny and his family’s decision for him to continue his season at USC and to enter the NBA draft. As opposed to Damar Hamlin, he very likely does have a risk for a recurrence of his cardiac arrest (mitigated by an implantable defibrillator, we think), but he had judged the benefit to be greater than the risk.
And just like Hamlin, I admire the young man’s courage and dedication to get back out on the court. He honors the game with his commitment, and he will be an inspiration for athletes who have suffered inestimable setbacks.
There’s another aspect to Bronny’s decision to continue playing. As opposed to most athletes, the carrot dangling in front of a professional sports career is not financial. Thanks to his father, the James family can enjoy generational wealth forever. But Bronny had the rare chance to reach the NBA while his father was still playing, and indeed last month they became the first father-son pair to play in an NBA game. To me, that moment had to be worth the miniscule risk.
All summer, Lebron has been criticized for Bronny’s inclusion on the Lakers’ roster. Ironically, nobody seems to want to question whether Bronny should be playing after his cardiac arrest. Instead, some people are apoplectic that Bronny is even in the NBA because he might not be an NBA-caliber player, at least not yet, after one abbreviated college season. It’s as if Lebron is the worst purveyor of nepotism ever, as if he is using his stature to manipulate a roster spot for his son. And to that I say a loud “So what?!”
Who really cares what the 15th player on an NBA roster does? He’s probably not going to be the difference on court between winning or losing a championship, or even a game. The last man on the bench needs to be either a player with potential for contribution 2-3 years down the line (and maybe Bronny is), or someone who brings some value in practice, in the huddle, or in the clubhouse. And for the Lakers, if having Bronny in the building is something that makes Lebron happy, give him a seat. And if that was Lebron’s dream 2 years ago, how do you think that magic moment felt last week, when the dream finally came to fruition, especially after he and his wife received that phone call last June and had to endure a torture that no parent ever wants to imagine?
I’ve literally heard people argue that Bronny shouldn’t be fast-tracked to the NBA roster because it sets a bad precedent for other players. It sets the stage for wanton and widespread athletic nepotism. And I submit that may be true. So the next time an all time great player, one who plays into his 40s and is the all-time leader in his sport, and who produces a son who is reasonably a major league caliber player and who reaches the league while his Dad is still a top 20 player in the sport, I guess he will expect his team to draft and keep his son. I think it’s safe to assume that’s not going to happen much. This time around, I think we can safely submit that the rules are different for Lebron James, and that’s going to just have to be OK.
But my favorite part of the story is this: we’ve all spent so much time ruminating over Lebron’s image, and his ego, and his self-consciousness. We’ve put him under a microscope that is reserved for only the very greatest. And now he’s telling us, loud and clear, that his most important basketball role now, his way of identifying himself, is as a father. As members of a society that may be slowly unraveling, especially in terms of family values, shouldn’t we actually be celebrating Lebron for that? Doesn’t this set him apart in a way that elevates him, like it elevates fatherhood, like it elevates family? Isn’t this really your favorite Lebron James moment? Can we forget “The Decision” now?
I'm hoping there’s room for me on the Lebron James bandwagon.
Better late than never!
~Patrick Flynn
