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A lacrosse ball hurled at 30-100 mph can kill a man. It’s been proven, unfortunately, 19 times since 1980. Sometimes the tragic but rare incidents make the national news, like when Cornell University defenseman George Boiardi stepped into a shot during a 2004 game against Binghamton. He stopped the shot with his body like any great defenseman might. His heart stopped and he died in front of his family, friends and fans. Things might have been different had an Automated External Defibrillator, or AED, been present to restart his heart, the way they do in hospitals routinely. His is the most recent death from sudden death cardiac arrest in lacrosse. The Boiardi family refused an autopsy but it is assumed that the occurrence of a phenomenon called commotio cordis caused his death. Some of the 19 deaths involved underlying and undetected heart conditions, but 10 cases were determined to be caused by blows that triggered commotio cordis which I will explain in more detail later. Boiardi was a standout player on a popular college team and his misfortune brought commotio cordis awareness and the AED issue to the attention of the nation.

While the death of Boiardi was a catalyst, prompting public demand and the most recent actions by US Lacrosse, AED manufacturers, school administrators and health researchers, it was Louis Acompora’s passing in 2000 that was the real precursor to the whole discussion about commotio cordis in lacrosse and the eventual movement toward the use of AEDs on our fields. The 14 year-old Long Island goalkeeper was hit in the chest with a medium speed shot. As he started up the field with the ball he collapsed and died of a sudden cardiac arrest. Accompora’s family, like Boyardi’s started a foundation to use the remembrance of their son to create awareness about commotio cordis and the use of AEDs. Both have been instrumental in changing the mindset among school and team administrators all over the country. The families have saved at least two lives in the process. In 2008 alone two high school players were revived by AEDs after heart stoppages on a lacrosse field.

23 lacrosse players in the United States have actually suffered a blow causing sudden death or cardiac arrest since 1980. 4 have lived. Alex Beuris of North Carolina’s Cardinal Gibbons high school was one of those lucky players that had access to a defibrillator on the field. In 2008 he was checked hard with a stick and nearly died as his heart stopped a few minutes later. Alex couldn’t have been more fortunate, as three doctors and four nurses were among the parents in attendance. His life was saved, after three electrical jolts from the miracle machine and all of the medical professionals on site that day agree that without the defibrillator, Alex would be gone.

Alex’s school bought the AED in 2001. Beuris remembers that as a freshman, his job was to carry the device to games. In 2007 U.S. Lacrosse teamed up with a cardiac monitoring manufacturer, Cardiac Science Corp. to help teams and leagues afford AEDs. The machines cost about 2,500 on the street, but schools and teams can get the life saving devices through US Lacrosse for under 1,500. This should be seen as a necessary and cheap investment for any school that offers lacrosse, baseball, softball, football and hockey according to studies by medical researchers.

Just this week, the Journal of Pediatrics published a research report which repeats the sentiment. The report claims that while it’s a million to one chance that a shot would cause death, lacrosse is “associated with excessive risk compared to other sports” according to the study’s leader, Dr. Barry Maron of the Minneapolis Heart Institute Foundation.

How rare is commotio cordis? If a shot hits the exact spot on a player’s chest, over the left ventricle of heart, at the precise moment in the heart’s rhythm; a moment which lasts for only 15 thousandths of a second on each beat, an electrical impulse which stops the heart can be triggered. The occurrence is a perfect storm of unlikely precision. The researchers stressed that cardiac arrest remains rare in lacrosse.

A million to one seems like an acceptable risk at first, especially for each of us, individually. The average goalie might face 450 shots a season and another 500 or so in practices. That puts each keeper at a 1 in 1052 chance. A defenseman is less at-risk, with perhaps a 1 in 3000 likelihood of incident. But lacrosse is the fastest growing high school and youth sport in America. The growth of the game each year multiplies the chances of it occurring somewhere. If there are 50 shots in an average lacrosse game and a team plays about 15 games a season in a league of 10 teams, only 266 leagues would produce a million shots. With summer leagues, high school, youth and middle school leagues in 50 states, at least one child would be affected per year on average. And that doesn’t include practices. Like I said, last year, there were two.

But defibrillators are not the solution. They are the safety net should all other measures fail. They’re effective only when one of our kids is already lying on the field with no pulse. We’d like to prevent these injuries instead of just mitigating the death toll once they occur. Certainly all schools should have an AED on the sidelines, but as a back-up. Something else is needed to protect kids from this random and tragic occurrence that statistically will happen again sometime very soon.

Some think the solution is in the rules. A movement was afoot after the Cornell incident in 2004 to make stepping into a ball after a shot illegal. The chairperson of US Lacrosse’s safety board, Dr. Margo Putukian has reportedly said that coaches should teach kids not to end up in front of shots on their way to the goal. Neither is a realistic option. We are dealing with intense and aggressive athletes who would, quite frankly, take the chance of getting hit, getting penalized and even the rare chance of being fatally wounded to stop the winning goal from occurring in a big game. They are warriors and shying away from that ball requires a characteristic they do not have at that moment.

Can you imagine how the implementation of a penalty would play out? A team is up by one in the last minute of an NCAA championship but the other team has the ball. With 20 seconds left a shot is taken and the defender steps in to eat the ball as he must in that scenario. He’s hit in the chest and he’s ok, but the penalty is called. The defender doesn’t pick up the ball and run out the time, winning the game. Instead, the ball is given back to the shooter. The defenseman has to leave the field while his team plays in a man down situation for 20 seconds and loses the National Championship. I wouldn’t watch that sport. Would you?

Women’s lacrosse has a “dangerous shot” rule that penalizes a shooter for letting one rip with a defender in the way. The rule rewards athleticism and the defender who can play perfect position defense. It’s a great rule for a game without helmets and pads. I’m not criticizing women’s lacrosse (today), but men don’t want that rule.

Others think the solution lies in the construction of the ball. A lacrosse ball is harder than balls in other sports and travels faster than most. It is a dense 5.25 ounce mass of hard rubber that has very little resilience or “give”. If you watch a slow motion picture of a small and pretty hard squash ball, for example, at the moment of impact on the squash court wall, you will see it compress fully. It will look flat as a pancake for a split second before bouncing back off the wall at a pretty good pace. The lacrosse ball would compress no more than maybe ¼ inch of its 2.5 inch diameter at great speeds. A squash ball is hollow in the middle while the lacrosse ball is not. Both are hard and hurt when they hit you at high speeds. Even though the squash ball can travel up to 170 miles per hour, it hits the body with far less impact, or we’d be talking about squash deaths.

If we were to learn from the squash ball, we would create a lacrosse ball that is just as heavy as it is now, bounces about the same off the turf, but was hollow in the center so it could compress upon impact. It would bounce off the pipe a bit more softly on close misses than it does currently, but we’d all get used to that and pipe shots would remain in play far more than they do now so it could improve the pace and flow of the game as a byproduct. But that still doesn’t prevent cases where the blow to the chest is from a hard check and not a shot.

There is an obvious need for better chest protection. In the 10 cases of commotio cordis related lacrosse deaths, four of the victims were goalies wearing chest protection. Because the condition is triggered by the precise position and timing of the blow and the density but not the speed of the ball, any goalie at any level is at as much risk as the next. Today’s pads take the impact and soften it, absorbing much of the impact. But since a 30 mph shot could cause commotio cordis, the impact of a 60 mph shot even after being diffused by about 50% could still kill. Most teen players can shoot in the 60’s and high school players often shoot in the 80’s. Chest protectors need to be redesigned to channel the entire impact away from the center of the chest.

But before the chest protector is redesigned, it needs to be redefined. The device is used by a goalie to do his every day job; stopping the ball. It already protects him adequately from the multitude of shots he fields in practices and games. But the next generation of chest protection must protect the player against the most catastrophic event, however rare, as well. While goalies throw themselves in front of every shot they can, the defensemen stand closer to the shots, have less time to react and usually wear no chest protection at all. And since it is our job as adults in the game to protect all of the kids standing between the shooter and the goal, we should design one for defensemen too. Perhaps even the shooter’s teammates that might find themselves in front of the goal on offense should wear them too.

In November of 2006, Dr. Vito A. Perriello, Jr., along with the Bollinger insurance company presented the “Risk Management Forum for Amateur Sports” on the topic of commotio cordis to US Lacrosse. Bollinger is US Lacrosse’s insurer. Two years ago, they recognized the following as “What we know”:

• Prevention is best treatment
• Quick recognition and action is critical
• Best treatment for an arrhythmia is defibrillation, like with an AED.
• CPR alone will rarely work
• Animal studies show AED at 1 minute yields 100% success, at 2 minutes 80% and at 4 or more minutes 0% survive
• Present chest protectors don’t work

In the “what we don’t know” section, they stated that we don’t even know if the current chest protectors prevent commotio cordis or possibly increase the chances, showing that we really don’t have a clue on this type of chest protection. And we have major lacrosse manufacturers that specialize in knowing the latest technologies and applying them to lacrosse. If Kevlar or titanium or air pockets were the answer, we’d already have the problem solved. They really need to start from scratch. The area we are trying to protect is much smaller than the area a chest protector covers. A successful device could be very small for all we know. Besides, the chest protectors already work for accomplishing the goalie’s regular duties. The designers need to toss that old chest protector aside and just focus on protecting that softball sized spot on the chest. If a smaller device works, all players could wear it and it could be incorporated into the chest protector for goalkeepers.

The lacrosse community could help, but there needs to be an incentive and a way for people with ideas to tell them to someone without committing the money or time to patent the idea. For good reason, the manufacturers don’t entertain unprotected ideas very often. If one were similar to an idea already being developed in the long process to actual production, how would they prove that? And how would someone prove that they did not? US Lacrosse could create a clearing house for ideas from individuals and give access to all of the manufacturers. We would know, of course, if anyone had already come up with an effective solution. It would be the hottest selling piece of equipment this year. If an idea in the clearing house is good enough to work, then it is obviously better than any which the manufacturers have had. This “open platform” of ideas for manufacturers would be monitored by US Lacrosse so they would know if someone ideas are used and award that person some predetermined dollar amount.

As compensation to the community for assisting them in this urgent endeavor, the manufacturers must also make the technology resulting from a suggestion an open platform. This means that all of the manufacturers can use the idea, even if it’s patented, in the interest of protecting all kids and not turning commotio cordis into a confusing marketing term like “offset” or “titanium”. I only propose this rather socialist approach because I personally have a few ideas I think would be very effective and even with my connections in the lacrosse industry, I would need to patent the ideas before any discussion with those who might implement them should they actually make sense to anyone but me. Maybe I’ll just publish them here. This is a pretty open platform.

http://boiardifoundation.org/ - Mario St. George Boiardi Foundation
http://www.la12.org/index.html - Louis Acompora Foundation

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