Death On The Basketball Court
Around midnight on New Year’s Eve, 2002, Kayla Burt, a sophomore guard on the University of Washington’s women’s basketball team, had just finished watching movies with friends and was getting ready for bed. The last thing that Burt recalls from that night was that, while brushing her teeth, she found herself chewing on the brush instead of going through the usual motions. Then everything went black. Burt collapsed as her heart stopped beating.
When Burt’s teammates saw her on the floor, they called 911 and started C.P.R. chest compressions until the ambulance arrived. The emergency responders resuscitated Burt from what was diagnosed as sudden cardiac arrest, stabilizing her heartbeat before she faded into a coma for the following fifteen hours. Although she doesn’t remember waking up, Burt’s family and teammates told her that the first thing she said was, “When’s practice?”
She would remain in the hospital for the next six days. Her cardiologists initially diagnosed her with long QT syndrome, an electrical abnormality of the heart that can cause life-threatening arrhythmias, or irregular heartbeats.
Following protocol for someone who had experienced a sudden cardiac arrest, Burt’s physicians suggested that she undergo a small surgical procedure to secure an implantable cardioverter defibrillator (I.C.D.), a medical device that is slipped under a pocket of skin near the collarbone, with thin and flexible silicone-coated wires that slide into the heart. The I.C.D. senses abnormal heartbeats and delivers strong electrical shocks that reboot the heart when it flutters dangerously out of control.
On her doctor’s advice, Burt sat out the remainder of the year, and all of the following season. She went to practices and travelled to games but was no longer competing. She struggled to comprehend the sudden change in her life. “Not only is being a sophomore in college a time when you’re figuring out who you are and learning more about yourself, but now here I was coming out of a life-or-death situation,” Burt told me.
Frustrated by the prospect of dealing with a premature career-ending and life-threatening condition, Burt decided to go to the Mayo Clinic to see Michael Ackerman, a cardiologist who specialized in long QT syndrome and other genetic abnormalities of the heart. Surprisingly, Ackerman informed Burt that she did not have long QT syndrome. In fact, he could not find one thing wrong with her heart.
Ackerman wasn’t the only one mystified by what had happened to Kayla Burt. Shortly after hearing about Burt’s collapse, Kimberly Harmon, the team physician for the University of Washington’s football and women’s basketball teams, began investigating the incidence and causes of sudden cardiac death (S.C.D.).
Working with Jonathan Drezner, a sports-medicine specialist at the University of Washington and a team physician for the Seattle Seahawks, Harmon found that the rate of S.C.D. in athletes that is cited in medical journals is often understated, mostly because the studies rely heavily on data from news reports. “Even the most rigorous search of media reports and news outlets misses about half the cases,” Drezner told me. Previous studies state that for a young, healthy person the chance of sudden cardiac death during exercise is one in two hundred thousand to one in two hundred and fifty thousand, which, according to Harmon and Drezner, largely underestimates reality.
In 2004, Robert Eckart, a former Army cardiologist now at the Heart Specialists of Sarasota, published a study showing that military recruits in populations that are similar to college athletes—male and female exercisers, eighteen to thirty-five years old—carry a risk of S.C.D. of roughly one in fifteen thousand, about twenty times higher than previous studies had reported. There is good reason to believe that these military numbers reflect reality more accurately than studies of athletes: Eckart’s findings used a military database, where all deaths must be catalogued and reported, whereas previous researchers, investigating S.C.D. in athletes, had to rely mostly on media reports and newspaper clippings.
Drezner and Harmon realized they had to get better numbers, and in 2011 they published a paper based on data of N.C.A.A. athlete deaths in a five-year period, from January of 2004 through December of 2008. They sifted through not only media reports but also catastrophic insurance claims and an internal N.C.A.A. database that collected some, but not all, college-athlete deaths each year.
Although Drezner and Harmon’s data weren’t as comprehensive as Eckart’s—because the reporting of death in college sports is not mandatory—what the researchers found was surprising. The rate of S.C.D. among N.C.A.A. athletes was about five times higher than where previous analyses had pinned it, and college-basketball players had the worst relative odds, one in eleven thousand. All of the other sports investigated—swimming, lacrosse, football, and cross-country running—appeared to be two to four times safer.
The data suggested that death during exercise threatened certain demographics. For instance, S.C.D. is much more prevalent in men than in women. Reports have also shown that African-American athletes may be more likely than white athletes to have heart defects that can lead to arrhythmias during exercise, and that their chance of dying from sudden cardiac arrest may increase two- to three-fold.
Mentioning sudden cardiac arrest and basketball immediately sparks memories of Hank Gathers and Reggie Lewis. Both stars died on the court from hypertrophic cardiomyopathy, a disorder that causes a thickening of the heart muscle, impeding its ability to pump blood. People with the condition—it is more common in African-Americans—often get short of breath or pass out during exercise. Both Gathers and Lewis had shown warning signs before they died, having collapsed on the court previously.
An elevated risk of sudden cardiac arrest may also be related to the body composition of college-basketball players; most are tall and lanky. Because of these elongated frames, physicians test larger basketball players for Marfan syndrome, a congenital disease that affects one in five thousand people and causes their connective tissue to grow larger than normal. Along with elongated appendages, Marfan syndrome can cause heart arrhythmias and increase the size of the aorta—the main blood vessel that pumps blood to the rest of the body—making it prone to aneurysm or rupture.
Harmon thinks that as researchers look at why people die when playing basketball as opposed to other sports, the results will show that, at times, genetic abnormalities are to blame, such as Marfan syndrome (because most players are tall) and hypertrophic cardiomyopathy (because most are African-American). Basketball has a much higher ratio of African-Americans than other sports, even football, Harmon said. But Drezner and Harmon’s statistics indicate that all Division I male basketball players, black or white, have an increased risk of sudden cardiac death, even though many of them possess no genetic defects.
To that end, Drezner and Harmon started looking into reasons other than genetics that might give basketball players a higher risk of S.C.D. In their studies, they found something even more confounding; Division I athletes had a higher rate of S.C.D. than Division II athletes, who, in turn, had a higher rate than those in Division III. Drezner and Harmon agree that the discrepancy may be related to the fact that journalists tend to cover more high-profile cardiac incidents (those in Division I schools) than those at lesser-known Division III schools, thereby increasing the number of reported cases. However, there may also be differing risks at different skill levels.
According to Drezner and Harmon, Division I teams, on average, spend much more time training than their Division III counterparts. Just as accruing more hours in a car would increase a person’s chance of a fatal accident, the more time that at-risk basketball players spend exposed to the sport, the more likely they may be to suffer an S.C.D. However, Drezner and Harmon warn that there is currently insufficient data to prove this hypothesis.
Another theory is that basketball players’ movement patterns are different from those of other athletes. The constant stop-and-start surges of high intensity, with marked changes in dynamics such as running and jumping, seem distinctive. In football, for instance, the average play might last six seconds. In basketball, minutes may go by before there is a break. Soccer and lacrosse players are spread wide on a field, while basketball players are confined to a small, hardwood court, giving them less time to decelerate. Basketball players generally change their speed much more frequently than, say, cross-country runners, which may lead to increased variations in basketball players’ heart rates.
Harmon said that the research team is now completing a study of ten years of data that will use the same methods as before, but will add autopsy data to address a criticism of their previous work. “The remarkable thing about our data is that it is really consistent,” she said: the researchers haven’t seen the ten-year numbers change compared to those in the five-year study.
“For the last thirty years, we’ve believed that hypertrophic cardiomyopathy is the leading cause of sudden cardiac death,” Harmon said. “But if you look at studies, the leading cause of sudden cardiac death is ‘autopsy-negative sudden unexplained death with no structural abnormality,’ ” which means that a majority of sudden deaths are still grossly unclassified, but probably caused by arrhythmia. Independently, Eckart found that thirty-five per cent of military-recruit deaths were unexplained. The lack of conclusive information observed in autopsies is similar to the dearth of clinical information in Burt’s case, where no abnormality could explain why she had almost died in 2002.
Preventing sudden cardiac arrests is difficult. In order to carry out a cost-effective strategy, doctors must better identify which demographics to screen. Based on the data, Harmon believes that all Division I basketball players, if not all college-basketball players, should undergo electrocardiogram (EKG) screening.
The International Olympic Committee, FIFA, and most major U.S. professional-sports associations all require participants to get an EKG during a physical examination. Drezner and Harmon are now leading the charge to screen all University of Washington athletes, regardless of their sport, and for the past six years have been collecting EKG data from incoming freshman student athletes. However, Eckart warns against relying on EKG or a non-invasive ultrasound imaging technique called an echocardiogram to identify athletes at risk, since the military did not observe a significant drop in sudden cardiac deaths over a twenty-five-year study even when they screened every entrant. “The biggest means for risk reduction is to identify those … who have a history of passing out without an identifiable cause, and those with a family history of sudden cardiac death in a family member before the age of thirty five,” Eckart wrote.
On August 17, 2004, Kayla Burt decided to return to the court, signing a waiver that indemnified the University of Washington in the case that she suffered another cardiac event. The way her doctors saw it, there was no medical evidence to suggest that exercise was the cause of the sudden cardiac arrest that she experienced two years earlier. She would be just as likely to have another incident whether she was playing basketball or at home watching TV.
Life went on as usual. Then, midway through her senior year of eligibility, during a television timeout, Burt’s defibrillator delivered a strong, jolting shock, four minutes into a game against U.C.L.A. Burt was conscious, and the shocks were causing her extreme pain. She left the floor and headed to the team’s locker-room tunnel, where she met with Harmon. Burt’s I.C.D. charged and dissipated once more. Her heart rate was firing at more than two hundred and seventy beats per minute. Though she had been completely asymptomatic during her time away from basketball, her heart was now in ventricular tachycardia, a condition that leaves the heart unable to deliver blood and oxygen to the body’s organs efficiently. The medical team worked with Burt to slow her breathing. She left the game knowing that this would be her final appearance as a player on the women’s basketball team.
These days, Burt is working two jobs and taking prerequisite classes as she prepares to apply to nursing school in the fall. She has become an advocate for educating athletes about the risk of sudden cardiac arrest and has teamed up with Harmon and Drezner to help screen up to five hundred students a month at different high schools through the Nick of Time Foundation, a nonprofit that raises awareness of sudden cardiac death in young athletes.
Burt stays active, running and working out on a regular basis, and she still participates in basketball—from the sidelines, by coaching a freshmen girl’s basketball team. Her I.C.D. has never fired since she left the court.
Story Credit: https://www.newyorker.com/tech/elements/death-on-the-basketball-court
