Another sudden sports-related death raises questions about whether such tragedies can be avoided, writes Kathy Sheridan.
When a non-smoking, non-drinking, fit, 29-year-old man died suddenly while playing soccer in Co Kilkenny last Sunday, the implications were almost overwhelming for a small rural parish. Michael Byrne died in almost exactly similar circumstances to his 25-year-old brother, Ken, who had collapsed on the same pitch 15 months before.
At Michael's funeral Mass on Wednesday, Grace Dermody, the 20-year-old girlfriend of Carmel Byrne's only remaining son, David, battled her tears and spoke for the family: "It's too sad, too difficult for our human minds to understand. As a family and a community we are heartbroken again."
On a rainy, autumn day, Michael's coffin was escorted up to Ballykeeffe Cemetery by a guard of honour from the River Rangers soccer club, to the strains of the Liverpool anthem, You'll Never Walk Alone. The unnatural silence and shocked, waxen faces of Michael's young team-mates - some of whom had seen both brothers die and seen other young tragedies in a parish with more than its share - told of a trauma that would not easily dissipate.
It was no time for recriminations. But it was already evident that this was a tragedy overladen not only with crushing grief, but with a wider bewilderment, a sense of guilt and on-going worry that no small parish or amateur sports club should have to carry alone.
Could Michael Byrne have been saved? The question hung over the dignified ceremonies. He had been given the all-clear by Dublin medical experts after his brother's death. What did that say about modern medical screening and the assurances of experts? In those early hours, it was assumed by friends of David - like his two brothers, a soccer fanatic - that he could never play soccer again; it would be "too hard" on his mother.
And then came the self-questioning. It came from those who had persuaded Michael - living a reserved life at home with his mother - to get out and play soccer to help him get over Ken's death; and from those in charge of local clubs who wondered whether an automated external defibrillator (AED) would have saved him.
Sure, team-mates experienced in cardiopulmonary resuscitation (CPR) and a nurse had been immediately on hand to administer first aid. But was it too little too late at that point? As this community now knows to its cost, there are no sure or easy answers, even from those who are authorities in such matters. But Kilkenny has now suffered four such sports-related young deaths in a year and a half.
By coincidence, on the night of Michael's funeral, Graigue-Ballycallan GAA club and its sister camogie club, St Brigid's, just down the road from River Rangers, were due to take delivery of an AED. Selected members had already done the required four-hour training course. The device (€2,200 plus 21 per cent VAT) plus the cost of the mandatory training course (€1,500) from a private company, had set it back over €4,000, no small outlay for a 250-member club whose main fund-raiser this year - a golf classic involving two months of hard organising by six dedicated members - yielded just €7,500.
Refresher courses at €150 a time are required twice a year. The prescribed ratio of trainees to instructor is five to one, so there is no question of accommodating several clubs in a session.
Despite their initiative, the mood among the club's directors was far from self-congratulatory.
"If getting the money for this was like climbing Mount Leinster to us, for a club like River Rangers, it'd be like climbing Mount Everest," said John Robinson, the club treasurer. River Rangers has 20 members. After paying all its bills in recent weeks, it has a total of €125 in the kitty. "We'd turn over about €4,000 in a year," said Gerry Dunne, the club secretary, whose desolation this week was palpable.
The VAT element is particularly resented. For Graigue-Ballycallan it was nearly €450. That a potentially life-saving machine - one recommended by the Irish Heart Foundation and due to feature in the forthcoming report from the National Task Force on Sudden Cardiac Death Syndrome - should be subject to the top VAT rate is beyond baffling to many. Another club in the midlands has spent several nervous months trying to persuade several VAT-registered local companies to buy the machine on their behalf, to save on the VAT.
"If there's no VAT on stretchers, why in God's name would you impose it on a defibrillator?" asked one official. So far, no company has stumped up.
Meanwhile, across a range of sports, there appears to be little or no meaningful leadership coming from headquarters on the subject of defibrillators; no guidelines, no directives, few to no training policies, still less any offers of grants or bulk-buying programmes. A soccer club which suffered a tragedy similar to River Rangers says that it didn't "even get as much as a phone call from the FAI, never mind advice".
The Muskerry GAA division in Munster has a scheme that offers a $500 grant to clubs towards the cost of an AED - "and that just about covers the VAT," remarks a member wryly.
But the general picture is that those groups wealthy enough to buy the machines are usually in the higher echelons of their sport, attracting spectator numbers that require the presence of bodies like the Order of Malta or Civil Defence who carry their own AEDs anyway.
Down the scale, small clubs are left alone to worry about where their responsibility begins and ends. Meanwhile, AED sales have become a highly lucrative line for a small number of healthcare companies and associated training firms. The brochures are slick and colourful and - intentionally or otherwise - the emotional pressure to buy is intense.
The brochure of one reputable healthcare company, Fleming Medical, spells it out: "When a person suffers a sudden cardiac arrest, for each minute that passes without defibrillation, their chance of survival decreases by 7-10 per cent. AEDs save lives!" It's no exaggeration. Maurice Wadding of the Active First Aid Training company, which works in association with Fleming, tells his audiences that the chances of surviving a sudden cardiac arrest in Ireland are just 1 per cent. "But in Seattle, where kids are trained in how to make proper emergency calls, in proper CPR, and where public areas such as libraries and shopping centres and police cars carry defibrillators, your chances climb to 40 per cent." Sales of AEDs have soared in recent months.
But even as Graigue-Ballycallan acquired its own AED, its chairman, John Caldbeck, was pretty certain that it was not the answer. "The real question is why are so many young lads dying like this? We have three pubs, four churches, one school, one GAA ground, one soccer pitch, one badminton hall, one cemetery. How many of these machines do we need?" Clubs with an AED are recommended to keep them in the club. But if say, a club has teams travelling to away venues where there is no AED, who if anyone, is responsible? Graigue-Ballycallan is only a five-minute drive from the soccer pitch but even if the GAA club had had its AED last Sunday and a trained operator available to use it, it would not have been close enough to save Michael Byrne. According to Maurice Wadding, 10 minutes is way too late.
"What I'm afraid of is that suddenly defibrillators are being seen as a kind of magic wand", says Gerry Dunne of River Rangers. "In an ideal situation, we'd all have a hospital two feet away. But the reality is that people die on mountains and out in the fields." And some even die in bed. The most high profile of last year's tragic sudden deaths was that of Cormac McAnallen, the Co Tyrone captain; he died at home.
Still, the clamour for AEDs is spreading. In the US, parent groups are campaigning for an AED for every team. But at Indiana University, the team doctor and director of sports, Dr James Nevins, who was instrumental in obtaining AEDs for the athletic department, confessed to reservations about them when interviewed by the Physician and Sportsmedicine journal. "I'm glad we have the AEDs, and they do provide a comfort zone, but is this a gut reaction?" He wondered if AEDs in the sports setting represented a "cultural veil of over-protectiveness" and if perceived liability concerns were driving the trend.
In the US, lawsuits have been brought against sites (including an amusement park and a health club) for failure to have an AED. Individual states have been careful to adopt laws to protect lay operators of AEDs from civil liability.
In an atmosphere of rising panic, context is everything. According to Dr Brian Maurer of the Irish Heart Foundation, out of some 6,300 sudden cardiac deaths in the country every year, an estimated 50 to 70 (0.79 to 1.11 per cent) occur among the under-35s; at least half of these are familial or genetically based.
The forthcoming Task Force report on Sudden Cardiac Death Syndrome (SCDS) will recommend that vulnerable young people and high performance athletes should be screened and treated insofar as a condition is recognised.
But by far the greater and more problematic cohort is the over-35s, and preventative strategies (smoking, blood pressure) will remain the focus. AEDs will be recommended for places of "public resort", says Dr Maurer. "But how we provide these, pay for them, ensure protection against liability and the trauma the people administering them suffer when they are unsuccessful, is another matter." AEDs, he notes, are only successful 20 to 30 per cent of the time.
Small places in rural areas will require a different model, he says, but for small clubs, "the likelihood [ of SCDS] is so low that it really wouldn't warrant the provision of one."
A study carried out in Cork and Kerry across golf clubs who had bought AEDs found that they were used about twice in five years.
What is it?: Formally known as Sudden Adult Death Syndrome, the term now used for this condition is Sudden Arrhythmic Disease Syndrome (Sads). This is a reference to the fact that it is the acute onset of a chaotic rhythm in the heart that leads to the victim's sudden death. Called fibrillation, the heart shakes like a piece of jelly and is unable to function properly. It is entirely different from a heart attack, which occurs when the blood supply to the heart itself is blocked.
What causes it? In those under 25, the common reasons for the development of an arrhythmia are the presence of different forms of heart muscle disease and anomalies in the structure of the blood vessels supplying the heart (the coronary arteries).
In addition to these causes, older victims may die because they have prematurely developed a blockage in their coronary arteries (coronary heart disease).
Regardless of the underlying cause, a common feature is the sudden development of an abnormal rhythm in the heart. This chaotic beating of the heart means that blood is no longer pumped into the brain and the heart itself leading to sudden death. The rapid application of an external electric shock may jolt the hearts electrical system back to a regular beat.
Is there a treatment? For those at high risk of the condition, the treatment of choice is to place an implantable cardiac defibrillator in the chest. This device automatically corrects the rhythm disturbance as soon as it starts. The availability of automatic external defibrillators at sports grounds may help in emergency treatment.
Are there risk factors? The main risk factors for Sads include a family history of unexplained sudden death in a relative under the age of 40. Unexplained fainting in young people is also a cause for concern. When Sads is suspected the person should be thoroughly investigated by a consultant cardiologist who will carry out tests in an effort to find an underlying cause. While the exact prevalence of Sads is unknown, it is estimated there are approximately 1,000 cases a year in Britain.
Dr Muiris Houston, Medical Correspondent