During a Monday Night Football game on January 2, Buffalo Bills safety Damar Hamlin went into cardiac arrest after what appeared to be a routine tackle, requiring cardiopulmonary resuscitation (CPR). His collapse has been seen by over 23 million viewers and counting, making it the most-watched Monday night ESPN telecast in history. He has since been discharged from the hospital, and people around the world, me included, are hoping he will make a full recovery. But, as a psychiatrist, I can’t stop thinking about everyone who witnessed him receive CPR, including the health professionals who administered it. Hamlin’s cardiac arrest sparked conversations about sports injuries and the importance of CPR training, but we need to start talking about the severe emotional distress that can be associated with seeing CPR, too.
Nothing really prepares you for CPR, even if you’re certified. Compressions on a mannequin pale in comparison to pressing on the chest of a person who was walking and breathing moments ago, and suddenly stops. Real-life CPR is not light and glamorous like the movies may portray it. It’s exhausting and forceful, violent even — enough to break ribs. The first time I did CPR, on a frail, elderly man who’d collapsed in the street, his chest gave way with a cracking sound that made me sick. Performing CPR is gut-wrenching and terrifying, and witnessing it is no better.
I remember waiting for my turn to take over compressions on the tiny chest of a toddler during my first year of residency. She was dancing and giggling in her hospital crib a few hours before, but now she was limp and motionless. Our medical team managed to get her heart beating again before it was my turn to do CPR, but I’d seen the whole thing anyway. I made it to the bathroom before bursting into tears. I suspect others struggled too, but we didn’t talk about it. We just kept working. There is significant stigma when it comes to healthcare workers seeking mental health support, and studies assessing the emotional distress surrounding in-hospital CPR are limited.
So, we suffer in silence.
But, as Hamlin’s catastrophic injury has reminded us, CPR happens outside of the hospital, too. As a psychiatrist, I am quite familiar with the emotional distress it can cause, for both bystanders and responders, which can manifest in many different ways. Sometimes, it looks like feelings of sadness or difficulty paying attention. Sometimes distress is more visceral, manifesting as physical symptoms like a stomachache or headache. Sometimes it is nothing in the moment, but after the emergency is all over and there is time and space to process, the stress hits you hard — trouble sleeping, intrusive thoughts of the traumatic event, feelings of hopelessness. These experiences can be normal after witnessing a traumatic event, like CPR, but they should wax and wane, lessening with time. But sometimes, they don’t.
One of my patients watched her mother receive CPR and was never the same. She started experiencing depressive symptoms, self-harming, and even attempting suicide. She developed insomnia, afraid to fall asleep because of recurrent nightmares.
“I just want to stop thinking about that day, but I can’t get it out of my head, even when I sleep,” she told me, sitting on the bathroom floor in the hospital.
To be sure, most people who witness CPR will not develop post-traumatic stress disorder (PTSD), like my patient did, as less than 10% of people develop PTSD after experiencing a traumatic event, but some may. Individuals who witness their relatives receiving CPR have been shown to develop PTSD, depression, and anxiety. But lay bystanders, even those who have no relationship with the person being resuscitated, have also been shown to develop emotional distress, including PTSD, as a result of administering CPR. Yet, the mental health sequelae of witnessing CPR, especially long-term, remains understudied and even some medical residents, like me, have reported symptoms of PTSD after participating in CPR events during training.
The pained expressions we all saw on the faces of Hamlin’s teammates should be a wake-up call. We need more research into the mental health effects of witnessing and performing CPR, both in the hospital and outside of it. We need to increase awareness of the psychological trauma surrounding CPR and urge people to seek professional mental health support if they are struggling, even for those who are healthcare professionals routinely administering it. We need to normalize the intense emotional distress that can come with CPR and make space and time for processing it through supportive debriefing. We also need to understand that some people may struggle with symptoms of depression, anxiety, or PTSD long after the CPR event itself.
Let’s follow the example of the Bills and Bengals players, who advocated to postpone the game after Hamlin was rushed to the hospital. Let’s understand that there may be more people than Hamlin who still need help recovering, even though a couple weeks have passed. Because after a person is resuscitated, business absolutely should not continue as normal.
Amanda J. Calhoun, MD, MPH, is an adult/child psychiatry resident at Yale Child Study Center/Yale School of Medicine.