Marcus Warren walked off the court and toward his seat on the bench. He plopped down and slouched onto a teammate. The frantic yells by his Camden High coach that came next overpowered the cheers, the squeaking shoes and the sound of a basketball bouncing that had been filling the gym.
When a trainer tried to get Marcus to sit up, his body slumped forward, and he collapsed onto to the court.
Marcus’ heart had stopped four days before Christmas in 2002. He was dead at 16 years old.
He was a seemingly healthy high school basketball player, until he wasn’t.
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Marcus’ unknown congenital heart condition could have caused sudden cardiac arrest at any moment, and it just happened to be on the basketball court. His heart abnormality was recognized for the first time in his autopsy.
Patricia Sims’ son, Vic Sims, was playing in the same basketball tournament. She watched from the stands in shock as trainers and medical personnel tried and failed repeatedly to revive Marcus. She looked for Marcus’ mother and didn’t see her.
“I was like, wow, who’s going to tell his momma?” Patricia said.
Four months later, Patricia got a call while on a business trip in Florida. Vic, a senior at Dutch Fork High, had collapsed while playing basketball. A pit formed in Patricia’s stomach. Her motherly intuition sensed something was very wrong. She recalled the image of Marcus on the gym floor, his mother absent.
Vic had died from sudden cardiac arrest. His family never knew Vic had an enlarged heart — a ticking time bomb in his chest.
“It was just so unbelievable,” Patricia said. “I don’t know if Little Vic would have lived or not, but at least if I had known, I could have sought the treatment that was needed.”
It’s been more than 10 years since Marcus and Vic died. The Midlands’ darkest chapter with sudden cardiac arrest included their deaths and two others — Brandon Butler from Columbia High and Lee Cannon from A.C. Flora — in a nine-month period.
South Carolina responded by putting an automated external defibrillator in every high school. But sudden cardiac arrest continues to be the No. 1 killer in youth sports, and the Sims and Warrens wonder if enough is being done.
South Carolina’s most recent high-profile sudden cardiac death is Ronald Rouse, who collapsed during a Hartsville football game in October 2012. Administration of a defibrillator on the field didn’t save his life, but his heart abnormality likely would have been caught in a heart screening.
Screenings for heart conditions in pre-participation physicals are increasingly rare and their practicality is one of the medical community’s hottest debates. Some see heart screenings as costly and often faulty, unnecessary for the average young athlete. Patricia Sims sees the potential to a save a child’s life.
“I really think people look at their children and think, I know it happens, but it’s not going to happen to me,” Patricia said. “People just don’t know enough about it.”
An electrocardiogram, or EKG, might have saved Vic Sims’ life, or potentially extended it.
He went to a family doctor for a physical every year, but Vic didn’t have symptoms of a heart condition and there wasn’t a family history of heart illness, the two criteria typical pre-participation physicals use to determine if an athlete should consider further testing such as an EKG or an echocardiogram.
An EKG measures the heart’s electrical efficiency and catches 60 percent of the heart conditions that cause sudden cardiac arrest in youth sports, such as an enlarged heart or hypertrophic cardiomyopathy. An echocardiogram is an ultrasound of the heart that shows the internal structure and how blood flows through it, and it would catch coronary artery disease and heart valve disorders.
The shortcoming with pre-participation physicals is that the majority of kids who have an undetected heart disorder don’t have symptoms or a family history of heart abnormalities, according to Seattle Seahawks team physician Jonathon Drezner. Sudden cardiac arrest is a silent killer.
“We know that just a pre-participation physical may not catch all of this, but it is at least designed to try and catch some of these kids that may not know they have a heart condition,” said David Geier, the director of the MUSC sports medicine program from 2005 to June 2013.
Drezner won’t conduct pre-participation physicals without an EKG because he said a history and physical alone are not a complete evaluation of someone’s heart. But if screenings were to become mandatory in pre-participation physicals, Drezner would start with the highest-risk groups — male basketball and football players, who he says account for 60 percent of sudden cardiac arrests in high school athletes.
The argument against EKGs in pre-participation physicals revolves around money. The cost to get an EKG and have it interpreted can vary from $25 to more than $100, but follow-up examinations for false-positives raise the price tag.
“There’s going to be a lot of false-positives and a lot of referrals to pediatric cardiologists that would be unnecessary,” Geier said. “There are a limited number of pediatric cardiologists, especially in the small towns. Who’s going to pay for the EKGs? Who’s going to pay for the follow-up examinations?”
A study done by two physicians at the University of Houston in 2010 estimated 16 percent of all athletes screened would have an EKG that registered a heart abnormality, but only 1.3 percent of those athletes with a positive screen would actually have a heart condition capable of causing sudden cardiac arrest. The annual estimates for EKG screening and follow-up examinations exceeded $126 million, according to the study.
Drezner agrees that a 15-20 percent false-positive rate is unacceptable and leads to a costly amount of follow-up evaluations, but it’s a problem that has a solution. Drezner said many physicians aren’t educated on how to read the EKG of an athlete where the normal athletic heart changes can mimic or overlap with some of the changes you might see with a heart disorder. Understanding screening in that setting produces fewer false-positives that lead to less unnecessary follow-up evaluations and less total cost.
“I think what people forget in the cost discussion is that what we do already costs a lot of money with almost no effectiveness,” Drezner said. “No matter what mathematical model you look at, the least cost-effective model is using history and physical alone. We already do the least cost-effective model.
“So yes, when you add an EKG screening, the total cost increases because you’re adding another test, but the cost effectiveness improves because you’re detecting more kids at risk for sudden cardiac arrest which is really the whole objective of doing any screen at all.”
The Sims said they partnered with the California-based Heart for Sports Foundation a few months after Vic died to provide discounted heart screenings at schools in the Midlands. But Patricia and Vic Sims Sr. said they were eventually asked to stop because the schools were concerned about the high false-positive rate.
South Carolina High School League director Jerome Singleton acknowledged that the high school league has explored the possibility of EKGs as part of pre-participation physicals after Rep. Gilda Cobb-Hunter proposed a bill in 2008 to make them mandatory. That bill never became law, fizzling out before a vote.
Paul Dobyns, the athletic trainer for Spring Valley High, doesn’t see the logistical feasibility. With the volume of athletes in the state and the scarce number of physicians who are trained to conduct and interpret EKGs, Dobyns doesn’t think it’s practical. He worries the costs could keep some from playing sports.
A University of South Carolina athletics spokesman said EKGs are not part of the standard testing protocol for its athletes unless heath history raises a red flag. Drezner said about half of Division I football teams undergo heart screenings.
“Is it going to change what has happened or what potentially could happen? I don’t think it will,” Dobyns said. “We’re still going to have fatalities because some of these anomalies just aren’t going to be caught.”
An EKG wouldn’t have saved Marcus Warren. His mother, Paula Warren-Radden, said Marcus had a valve that came off the wrong side of his heart as well as a narrowing in his aorta.
But she and the Simses said they never knew about the prevalence of sudden cardiac arrest in youth sports or the potential benefit in heart screenings. Dobyns said a conversation with parents about getting an EKG outside of a pre-participation physical wouldn’t happen unless something in the physical was an indicator that a heart condition was a possibility.
“Unless we’re looking at something on a health history, then we probably wouldn’t recommend it,” Dobyns said. “As we’re educating parents on concussions nowadays, it’s probably not a bad idea to educate them on other things like this.”
AUTOMATED EXTERNAL DEFIBRILLATORS
Joni Canter’s student athletic trainer at the School of the Deaf and the Blind asked the same question every day. Why did they always need to bring the black box with the defibrillator to the field when it was so heavy?
When Ther Tee Vang collapsed during a football practice in 2011, Canter’s student trainer had her answer. Canter couldn’t find a pulse, and one shock of the automated external defibrillator started his heart just in time for the ambulance to arrive.
“It’s like it happened yesterday,” Canter said. “Had the defibrillator not been there, I think we could have all determined what would’ve happened. The outcome would have been completely different. With just CPR alone, there wouldn’t have been enough force by anybody to change the rhythm of his heart.”
There is no debate within the medical community surrounding automated external defibrillators, or AEDs. The devices used to stimulate a stopped heart through electrical shock are widely considered a necessity in schools.
A state that consistently ranks near the bottom in the country in educational standards, South Carolina is one of the nation’s leaders in defibrillator legislation. State law requires an AED in every high school, though it doesn’t provide funding for the AEDs and there’s no penalty for not having one. Toothless as the law may be, Singleton said the SCHSL’s most-recent survey reported an AED in all of its member schools. Drezner said his research suggests that 50 percent of high schools in the country have AEDs on site.
Former state Rep. Denny Woodall Neilson sponsored the AED legislation in 2008 and said it was the most positive reaction she’s ever gotten from her constituents.
“The lives of our children are very valuable, and we need to make sure we have a safe environment for them,” she said. “Along with that, we need to make sure we have the facilities or equipment to take care of them.”
Ten years ago, both AEDs and athletic trainers were rare, a casualty of shrinking school budgets. Of the 133 schools that responded to a survey by The State in 2003, 12 reported they had AEDs on campus.
The string of deaths in nine months that started with Marcus Warren and Vic Sims touched off a wave of generosity. Hospitals and foundations donated AEDs to their surrounding schools. If high schools could come up with funds for half the cost of an AED, the high school league agreed to provide money for the other half.
An AED might have saved Vic Sims when he collapsed in Dreher High’s gym. The Simses find some satisfaction in knowing that other lives can potentially be saved because of the awareness Vic’s death brought to the issue.
“It has come a long way from when it was 2003 until now,” Patricia said. “What we were trying to do was bring awareness because you don’t want anyone to experience what we did if they don’t have to.”
Said Vic Sims Sr.: “I don’t know if an AED would have saved him or not, but it should have been there.”
Even though doctors told the Warren family an AED wouldn’t have saved Marcus’ life, the family used the donated funds from the basketball tournament Marcus died playing in to purchase an AED for Camden High.
Athletic trainer Brian Bishop saved a life because Mauldin High had an AED. In January 2004, when very few schools in the state had defibrillators, Bishop used an AED when 17-year-old Philip Davis’ heart stopped during a JV basketball game at Mauldin. Bishop was able to get a pulse before the ambulance arrived.
“There’s no doubt in my mind that if we had not had an AED on campus, that would not have worked out the way it did,” Bishop said. “Philip probably would have passed on right there on the basketball court.”
The effectiveness of an AED depends on the response time, said Ron Courson, senior associate athletic director of sports medicine at the University of Georgia. Courson said the chance of survival decreases by 10 percent with every minute that passes after a heart has stopped beating, so ideally an AED would be administered within three minutes. CPR alone isn’t enough to start the heart beating after it’s stopped, though it is an important tool to buy time.
But like electrocardiograms and other heart screenings, defibrillators aren’t foolproof and won’t save everyone. Hartsville High football player Ronald Rouse died from “a fatal sudden cardiac arrhythmia resulting from a congenital enlarged heart,” Darlington County Coroner J. Todd Hardee announced in October 2012 after Rouse’s death. An AED used on the field didn’t start his heart.
“It brings it all back – the initial shock,” said Paula Warren-Radden, Marcus’ mom. “You know what they’re going through because you’ve been there. Each one kind of brings it back.”
Sudden cardiac arrest takes a victim in youth sports every two or three days on average. The Simses frequently get emails from friends or acquaintances when there’s a sudden cardiac death on a playing field.
“A kid just died in Atlanta,” Vic Sims Sr. said as a reporter entered his home.
The Simses used to be more active in raising awareness about underlying heart conditions in young athletes when they worked with the Heart for Sports Foundation. Patricia was the organization’s contact in South Carolina and would speak at functions and forums about the importance of heart screenings.
But as more time passed without a high-profile sudden cardiac death in the state, the uptick in awareness from the string of four deaths in 2002 to 2003 faded. At least in the near future, mandatory EKGs in pre-participation physicals are unlikely, as the American Heart Association didn’t recommend it in a June 2012 policy guidance memo.
The Simses are in the same predicament as the Warrens — hoping it doesn’t take another death to influence change.
“It’s not ‘if it happens,’ but ‘when it happens,’ ” Patricia said. “I hope it’s not your child.”