For student athletes, defibrillators remain out of reach

Today would have been Nicholas Rotolo’s 24th birthday.

Rotolo, a Berkeley High School student and club hockey player, stood a brawny 6’2″ tall, weighed 220 pounds, and had no apparent health issues. But on February 5, 2004, the 17-year-old suddenly collapsed on the rink at Sharks Ice in San Jose while competing in an exhibition for his San Jose Junior Sharks team.

“I don’t really recall what happened just before Nic went down,” said his mother Christine Rotolo, a quiver in her voice. “A lot of people say that he had gotten checked just before. But the whistle had blown, and next thing I knew he was on the ground. And when you see a kid on the ground, the first thing you do as a parent is you check all the jersey numbers, and you’re looking for your kid. And then it’s like, ‘Oh my God, that’s Nic.’”

As multiple people fired off phone calls to emergency responders, two parents raced down from the stands and performed CPR. Rotolo was rushed to San Jose Medical Center, but never regained consciousness. Although several attempts were made to determine the cause, the circumstances surrounding his death remained cloudy. Originally labeled cardiac arrest resulting from a blunt trauma to his chest, the coroner later changed the cause of Rotolo’s death to a different malfunction of his heart, which created an irregular heartbeat.

Regardless of what actually killed Rotolo, his mother believes that his life may have been saved had an automated external defibrillator (AED) been used to revive him. There actually was a defibrillator at what was then known as Logitech Ice Center; it hung from the wall only a brief skate away from where he laid motionless. But according to a lawsuit later filed by Rotolo’s mother, because none of the arena personnel informed any of the coaches, officials or participants of its existence, no one knew of its availability.

According to Jonathan Drezner, a family physician at the University of Washington’s Department of Family Medicine and an expert on the use of defibrillators in athletic settings, the combination of CPR and a defibrillator can mean the difference between life and death. “We’re seeing that early CPR and early defibrillation is what saves lives,” said Drezner. “It’s a simple equation.”

A defibrillator, sometimes better known as a “heart shock box,” delivers an electric jolt to someone whose heartbeat has been knocked out of its regular rhythm. The user attaches electrodes to the victim’s chest, and if the machine detects an abnormal beat, the operator is prompted to administer a shock with the push of a button. The device will not produce an electric charge unless it recognizes a lethal heart rhythm, and usually only one shock is necessary.

Although Drezner said survival is never guaranteed, without the immediate use of a defibrillator, chances diminish dramatically. “Without CPR and an AED within minutes,” he said, “the chance of survival declines rapidly with every minute treatment is delayed, about ten percent every minute.”

Rotolo’s death, along with a string of other catastrophic heart-related injuries among young athletes around the country since, has helped make the issue of defibrillator access a national health concern. According to Drezner, sudden cardiac arrest strikes approximately one in every 50,000 athletes from middle school through college. That’s a total of between 150 and 200 cases each year. Drezner says that injuries occur most frequently in high schoolers, because of the sheer number of participants in school sports, and because people at that age are more prone to heart-related events.

During the 2010 high school football season alone, there have been two confirmed cases of catastrophic heart injuries in the United States among high school players—one in Oregon and another in Florida. Both boys beat the odds and survived without the use of a defibrillator. This was not the case for another football player in Texas, whose mysterious death is still being investigated. Despite an autopsy, the coroner has still not been able to rule out arrhythmia, or irregular heartbeat, as the cause of death for this 17-year-old quarterback.

Last year, two Bay Area high school basketball players died from heart-related complications while participating in their sport, and another survived a near-lethal cardiac arrest.

No one would ever think to quantify the value of a human life, especially that of a child. And yet, the cost of defibrillators—no more than $2,000 apiece—often stops teams and sports facilities from providing them for young athletes. Even when they are available, someone trained in how to use it is not necessarily present during emergencies. For Christine Rotolo, and other parents like her, who believe these devices could have prevented their children’s deaths, the cost of not having one available is made tangible by the emptiness they feel every day. Rotolo said she’d gladly pay that amount to have Nic alive today. “It seems like a small cost to me,” said Rotolo. “I’d pay hundreds of thousands of dollars for one at this point.”

* * *

Bruce Valentine of Children’s Hospital Oakland says that although instances of cardiac arrest in youth sports are relatively infrequent, he sees them as a major concern. “They are not a common problem,” said Valentine, who helps manage the athletic training program in the hospital’s Sports Medicine Center for Young Athletes, “but when it happens, it’s devastating, and much more than concussions.”

While concussions and other brain injuries persist as the biggest headline grabber in sports health today—with new regulations recently established in some of the professional leagues, as well as new state-by-state bylaws for youth sports—heart-related catastrophic injuries are actually much more likely to result in death, said Drezner. “By far, sudden cardiac arrest is the leading medical cause of death among young athletes on the playing field or during exercise, which accounts for about three-quarters of all deaths,” he said. “That’s more than head- and neck-related, seizures, asthma and heat-associated deaths combined.”

Worse, he points out, in up to 80 percent of young athletes who experience cardiac arrest while playing sports, there are no symptoms to act as warning signs.

Though many people think that heart-related injuries can only occur in full-contact sports such as football, hockey or lacrosse, “These types of injuries can happen with any sport,” said Valentine. “The risk is inherent throughout the entire athletic department.”

Drezner says that having a defibrillator and a good school emergency plan can make all the difference in a student athlete’s chances of survival. “A study in 2009 of 1,700 high schools around the country showed that for those that had an AED with people that knew how to use them, the survival rate was over 60 percent,” he said. “Of those schools that did not, the survival rate was maybe ten percent.”

But without state or federal laws in place to mandate defibrillators, the majority of schools across the country remain without this crucial device on site.At present, only 14 states have legislation requiring schools to have defibrillators. California—the country’s most populous state—is not one of them.

In addition, the California Interscholastic Federation (CIF), the organization in charge of setting all of the safety and competition guidelines for the state’s ten high school athletic sections, currently does not require that defibrillators beon the sidelines of any athletic events, games or practices.

“In a perfect world, we’d have AEDs everywhere,” said Roger Blake, associate executive director of the federation, “but the cost of the units makes it so such a thing is not feasible.”

Portable defibrillators used to cost as much as $3,000, but prices have dropped in the past few years. They now cost between $750 and $1,000 for medical providers, and between $1,500 and $2,000 for someone off the street, not including occasional fees for maintenance and calibration.

“Everybody agrees that it’s a good idea,” said Valentine, “but nobody agrees on who should be responsible for paying for it. No one is stepping up to provide them.”

Because of this, most schools, teams or sports facilities are forced to pay for the devices out of their own pockets, unless they can find a private donor. At a time when some youth teams struggle just to afford matching jerseys, they don’t have the money to fork over nearly $2,000 for something that may never be used.

While the Oakland Athletic League (OAL), which is made up of six public schools as well as a 15-school charter league, complies with all CIF rules, its bylaws do not require that a defibrillator be on site for games or practices. Even for football and basketball—the league’s two marquee sports, and those associated with the most heart-related deaths—no regulations are in place.

Johnny Lorigo, who manages eligibility and compliance for the league, said he thinks the lack of these devices is probably associated with the school district’s financial circumstances—the district was forced to cut $122 million from the budget for the current 2010-11 school year, and even more cuts are expected for 2011-12. “I’m guessing it could have something to do with cost,” said the 34-year league veteran, who was formerly the athletic director at Castlemont High School. “With 22 sports at each school, how can you have one at every practice and game? Could you imagine how much that would cost us?”

Drezner sympathizes with schools and teams that face tight budget constraints, but emphasizes the importance of having immediate access to this life-saving tool. “Financial realities make it very difficult to decide what to spend money on,” he said. “But by purchasing the device, schools can decide to make student safety a primary goal.” He suggested schools or parent organizations hold fundraisers such as bake sales to purchase at least one defibrillator, which is generally good for up to ten years. Drezner also recommended making sure it is centrally located, and that there is a strategic emergency communication system in place in the case that it is ever needed.

Christine Rotolo echoed these ideas for parents of kids who play on a team without access to a defibrillator. “I’d consider grouping together with the other parents and pitching in, even if it’s a couple hundred dollars per family,” she said. “And if you don’t need it, and you waste $2,000, well then, actually, you should celebrate.”

* * *

Born in Walnut Creek, Nic Rotolo started playing youth hockey at age 3, and also played baseball until he had to choose between the two. “Hockey won,” said his mother. He spent most of his childhood in Piedmont, followed by a move to Berkeley during high school when his mother remarried. He went on to play for several competitive teams that traveled to the extent that it made it difficult for him to attend a conventional high school.

“Our life was hockey,” said his mother, recalling the drive from Berkeley that she and Nic made several times a week for practices and games when he began playing out of the San Jose arena once he began high school. “My friends thought I was nuts. But it was great. When he wasn’t at school, and he wasn’t playing hockey, he was hanging out with his friends, so the time I got with him was the driving time. That was our quality time.”

As a junior at Berkeley High, Rotolo was already fashioning a collegiate hockey career for himself, and dreaming of making it to the pro ranks. After playing on a summer team that traveled to Boston, the talented, young defenseman hoped to play on the East Coast. “He would have loved to have gone to Boston. He loved Boston,” said his mother.

The evening of the first Thursday in February 2004 began with much excitement for Nic Rotolo and his family. His grandparents had traveled from out of town and sat alongside his parents for the rare opportunity to watch him play for his Junior Sharks in a home game.

Then Rotolo went down. His mother sprinted from the stands to come to his aid. Two other team moms with experience in nursing and emergency response did the same. “Several people called 911 and somebody handed me a phone while I was trying to get a pulse,” Rotolo recalled. “And they were asking, ‘Is there an AED?’ I didn’t even know what that was. And it could have saved his life.”

There was, in fact, an AED on the wall nearby. No one thought to look for it though, said Rotolo’s mother, because no one knew it was there.

Even though those on the scene applied CPR while everyone frantically awaited the arrival of emergency personnel, Nic never recovered. He was pronounced dead shortly after emergency responders took him to San Jose Medical Center.

Initial reports from Rotolo’s autopsy, as well as review of the videotape, were both inconclusive in revealing the cause of his death. Later analysis of the film suggested that what appeared to be a relatively harmless knock to Nic’s chest by an opponent’s shoulder during play may have caused an uncommon disorder known as commotio cordis, ultimately leading to sudden cardiac arrest.

Commotio cordis is a blunt trauma to the chest that results in a lethal heart rhythm due to what Drezner called “precise and unfortunate timing.” It creates no structural damage to the heart, and is seen most frequently in lacrosse and hockey injuries.

An amended death certificate was released a couple of months later by the Santa Clara County Coroner’s Office changing the cause of Rotolo’s death to an arrhythmia associated with myocarditis, an inflammation of the heart muscle that is most commonly caused by a viral infection. Upon modifying the cause of Rotolo’s death, the coroner explained that Rotolo had previously suffered from an infection.

Hypertrophic cardiomyopathy, which was not suspected in Rotolo’s case, is another condition associated with sudden cardiac arrest in young athletes. It is characterized by an abnormal enlargement of the heart due to a genetic disorder and accounts for one third of all catastrophic heart-related injuries among young athletes.

Rotolo’s death weighed extremely heavily on the family he left behind, his teammates and schoolmates. More than 700 people attended his funeral. “He was just a really big-hearted person,” said his mother. “He cared about people and people’s well being. He was a good friend to his friends. He was funny and fun to be with. He was just a really great person.”

In 2007, claiming negligence directly resulting in his wrongful death, Rotolo’s family sued the operators of the ice arena, San Jose Sports and Entertainment, which also owns the San Jose Sharks. The family contended that facility personnel had an obligation to inform patrons of the existence and its location of the rink’s defibrillator, and argued that its use could have greatly increased Rotolo’s chances of survival. A trial court ruled in favor of the arena, and so did an appellate court, finding that California’s legislative statutes do not impose a duty of notice on building managers.

Christine Rotolo preferred not to discuss the lawsuit. “It kind of brings up really painful stuff,” she said.

She has only set foot in an ice rink once since her son’s death, to hang a homemade memorial plaque and framed picture of him at the Oakland Ice Arena, where he participated in countless games and practices while growing up. His former coach, André Lacroix, a former professional player, who was then managing the arena, asked for one of his jerseys to hang near the scoreboard, as well as a photograph of him for the arena’s entrance. According to staff at Oakland Ice and the San Jose arena where Rotolo collapsed, both facilities have a defibrillator today.

Rotolo’s mother can no longer bring herself to watch hockey. “I can barely even see it on TV,” she said. “It was something that I loved so much that I shared with him, that it’s—I can’t even,” she trailed off looking downward. “I don’t know,” she said “It’s just really hard.”

* * *

Although organizations like the California Athletic Trainers’ Association (CATA) continue to push for state legislation to make defibrillators a requirement in schools and athletic settings, passage is an arduous task.

This year, California State Assemblymember Mary Hayashi of Hayward proposed a bill addressing the need for defibrillators in youth sports. Assembly Bill 1647 would have required school districts offering athletic programs to acquire at least a single defibrillator by July 1, 2014, and to make it available at each school site for school-sponsored athletic activities. The bill would have also required the districts to have an emergency action plan by July 1, 2011.

However, Mike West, president of CATA, notes that the clause about defibrillators was removed due to financial limitations during the appropriations process. The bill that was sent to Governor Arnold Schwarzenegger—which he subsequently vetoed—was solely about athletic trainer certification.

According to West, no one in the legislature is philosophically opposed to requirements for defibrillators. “The main roadblock is the issue of cost because if a mandate is created, then the state must come up with the devices or the money for them,” he said.

Valentine, a member of the trainers’ association, believes that two of the organization’s recommendations would go a long way in making athletic participation safer when defibrillators are not present. “First, all high schools should have an athletic trainer on staff,” said Valentine, “or at least there should be one on a daily basis at practices and games. And second, athletes’ should get a good preseason pre-participation physical examination, preferably by their own physician.”

West said that the trainers’ association estimates that only 20 percent of California schools have a certified athletic trainer on staff, and less than 40 percent have one on site at least once a week. Without a CIF bylaw requiring medical personnel to attend games and practices, each local section or league has the ability to determine their own guidelines for on-site personnel.

The Oakland Athletic League has slightly stricter regulations in place than the CIF requires: for football games, officials cannot permit kickoff until a medically trained staff member is present. Lorigo says that the league also tries to have licensed personnel at all postseason basketball games as well.

But with no laws in place to require defibrillators for schools and various youth sports, and no legislation currently in the works, most parents, teams and schools will either have to come up with their own funds to ensure a defibrillator is accessible, or forgo one at the risk of their athletes’ health.

A handful of nonprofit organizations work to place defibrillators in schools, sports facilities and public areas, most notably professional basketball player Ronny Turiaf’s Heart to Heart Foundation and former professional hockey player Jiri Fischer’s Healthy Hope Foundation. Both men started their nonprofits after developing serious heart-related conditions of their own during their athletic careers.

With hockey season right around the corner, Christine Rotolo has advice for all parents of athletes. “I think that if I was a hockey parent now, knowing what I know, or like a sporting parent, I would take as much initiative as I could to try and know as much as I could,” she said. “Be on top of CPR, and know what an AED is. Look for it in the institutions where your kid is going to be playing, and know how to use it, or know who knows how to use it.”

After enduring the loss of her son, Rotolo worries about other athletes’ parents who are unaware of the risks associated with playing sports—she was once a part of that group. She can’t help but relive her son’s death each time she hears of another young athlete suffering a cardiac arrest.

“When I hear about kids collapsing,” she said, “I’m always so relieved to hear that they made it through because there was either an AED or there was somebody that was there and knew what to do. And then I feel really horrible for the parents of the kids that don’t make it. It’s just horrible. It’s a very surreal place to go. And you don’t want to go there.”

Image: A framed photograph and plaque of Nic Rotolo adorn the entrance of the Oakland Ice Arena. Rotolo’s mother, who constructed the memorial, has not set foot in an ice arena since hanging the tribute to her fallen son.