As she sat in the batting cage cradling her son Jack's head in her lap, Nancy Crowley knew he was dying. His face was turning blue. That awful unnatural blue no mother should ever have to see. As other parents screamed for an ambulance and grandmothers began to pray out loud, all Nancy could do was look into Jack's eyes, trying to memorize every detail in those blue eyes one last time before they closed.
The same eyes that just minutes earlier, while his younger brother was playing in a Little League game, had begged his mother to let him go to the local 7-Eleven across the street. Nancy said no. Even though Jack was 14 years old, crossing the busy street was just too dangerous.
Instead, Nancy sent Jack and his middle brother, Aidan, to the batting cage about 30 yards away. But now another parent was beating on Jack's chest, doing CPR. There was so much confusion. No one understood why Jack, always so healthy, suddenly collapsed. He'd been pitching, and now he wasn't breathing. "Come back to me," she begged. "Don't leave me." Even though his eyes were open, Nancy knew Jack couldn't see her. She knew he was already gone.
But what Nancy didn't know was that 17 years earlier, another mother had once also held her teenage son, begging him to wake up, after he too collapsed on the field while playing his favorite sport. The death of Louis Acompora would send his mother, Karen, on a journey to solve one of sport's biggest medical mysteries. Something many had written off as an unexplained fluke but, as Karen would learn, is in actuality the second-leading cause of sudden death in youth sport. Karen Acompora would make it her life's mission to raise enough money and push enough experts to find a way to prevent boys from needlessly dying on the field. Boys like Jack.
Louis Acompora grew up in New York on Long Island, where lacrosse is practically a religion. His father, John, played the sport and couldn't wait for his only son to play too. "He showed up at the hospital with this little lacrosse stick," Karen laughs as she remembers the day. John smiles as he remembers how, "When Louis was old enough to walk, he was dragging that lacrosse stick around with him."
As he grew, his parents realized Louis hated to lose. Trying to harness that passion, John impressed upon his son the importance of good sportsmanship and never giving up. "You never give up," John would chant. "You never quit. Whether it be lacrosse or school or anything in life, you see it through."
By fifth grade, Louis decided to give goalie a try. "I said, 'It's a great position because right here, on the cul-de-sac, I could practice with you as much as you like,'" John says. "And that's where we spent the next four years. Me shooting at him in the cul-de-sac." But now, when John stands in the quiet street in front of his house where they used to play together, he admits, "I wish I wasn't that encouraging for him to be a goalie."
Louis was named captain of his freshman high school team when he was 14 years old, before he had even played a game. He was nervous when the time came to actually play. "I said, 'Don't worry. You're going to be fine,'" John recalls. He and Karen were running around that Saturday morning, trying to get from their daughter's lacrosse game to their son's game. "It was chaotic," Karen remembers. The last thing Louis said to her as he walked out the kitchen door was, "Don't be late."
They were late. "We were the visiting team," Karen says. "We got lost." She remembers how Louis was already in the goal, looking for them in the stands, when he saw them. He waved and then "turned into a brick wall in front of that goal," John says, explaining how it was the best game of Louis' life. He blocked shot after shot throughout the first quarter. "I remember saying to myself, 'He's a one-man wrecking crew.'"
But in the second quarter, "A boy came across the center of the field and Louis was screened." Another player from the opposing team was purposefully blocking Louis' view of the overhand shot on goal. "It wasn't a hard shot. It wasn't a rocket shot," John says. "It was from a distance."
"Just hit him in the chest," Karen says, nearly choking on her words. "The ball dropped, and he scooped to pick it up and he collapsed."
Karen told John to go on the field, but John hesitated, "I didn't want to run out there and be a neurotic parent," John explains. But as Louis continued to lie prone on the field, unmoving, John moved quickly toward his son. "I could hear his coach saying, 'Louis, answer me. Louis, wake up.'" John then heard Louis take what he thought was "a deep, deliberate breath" followed by a gurgling sound. "I remember saying, 'Come on, Louis. Take another breath.'"
John now realizes Louis was taking an agonal breath. It's wasn't a real breath but instead a warning of imminent death often associated with cardiac arrest. A young athletic trainer on the field started yelling that Louis didn't have a pulse. "We got his chest protector off to the side," John remembers. "His coach started CPR. And I knew relatively soon he was in big trouble." John pauses and then simply says, "Because he had started to turn blue."
By now Karen had joined her husband on the field. As they pounded on her child's chest, "I was begging him to wake up." Begging him not to leave her. Begging him to come back.
But Louis was gone.
"When Louis passed away, the medical examiner had no idea what killed him." This is when Karen, a petite woman full of unbridled energy, becomes fiery, remembering their exchange with the medical examiner. "He said, 'Well, you know, the only thing I can say is natural causes.' It's like, he didn't die from natural causes."
Louis was "perfectly healthy," John explains. "He had no pre-existing conditions whatsoever. He was in incredible shape. Drug-free."
Karen says it's difficult to imagine today, but when Louis died in March 2000, she didn't have the internet to help her figure out what had happened. She did it the old-fashioned way, making phone calls, reading old newspaper articles and poring over medical journals. Because even though the medical examiner wanted to write "natural causes" on the death certificate, he suspected the lacrosse ball might have had something to do with it.
Seizing on that idea, Karen called a young cardiac fellow at Tufts University. "No one knew why Louis died," Dr. Mark Link remembers. "She searched for answers. She tried to find out. And that's how she came to me."
Link, who now works at UT Southwestern, was just starting out in his career and was trying to figure out why some children die when they're hit with a hard ball. Karen vividly remembers their first phone call. "He said, 'I'm going to tell you what you're describing to me was commotio cordis."
In Latin, commotio means "commotion" and cordis means "heart." "So, it's commotion of the heart," Link says. "It is a tragic, unfortunate event that happens to normal, healthy kids when they're struck in the chest. But there has to be multiple things that occur at the same time."
A teenager's rib cage is more flexible than an adult's, which means a sudden blow to the chest can cause the ribs to bend inward and touch the heart. "That allows the energy of the ball to be transmitted to the heart," Link explains. If the blow hits at "the upstroke of the T wave," in the last part of a heartbeat -- a window of time that's 15 times faster than the blink of an eye -- the heart will go into ventricular fibrillation.
"The heart is being electrocuted," Dr. Link says. "It's the sudden-death rhythm. The pumping chambers just quiver. When they quiver, they can't effectively pump blood. There's no blood flow to the brain."
It takes five to six seconds for the interrupted blood flow to reach the brain, meaning players like Louis will often take a couple of steps before their brain's blood supply is cut off. When the blood flow stops, the player will faint and fall to the ground. "If the blood flow is not restored within four to five minutes," Link says, "the brain will die."
Link says what happened to Louis was a classic case of commotio cordis. Karen remembers how Louis would often come home covered in bruises because dozens of balls would hit him whenever they practiced. "I never knew that could even be a possibility. That a ball hitting Louis, which had hit him hundreds, maybe even thousands of times prior, could kill him."
Mike Oliver, a big Midwestern lawyer, is the Executive Director of the National Operating Committee on Standards for Athletic Equipment. He admits it's a name with a lot of words. "That's why we say NOCSAE," he says, pronouncing it "knock-see."
Oliver says NOCSAE was created in the late 1960s when nearly 30 football players a year were dying while playing the sport. "There were no standards for helmets," Oliver explains. NOCSAE has since created more than 24 standards for everything from baseball batting helmets to soccer shin guards. To pass a standard, a company must meet a long list of requirements that show its product will prevent specific types of injuries. Manufacturers go through an extensive audit and rigorous testing by an accredited independent third party to obtain certification to the NOCSAE standard.
Oliver remembers how, while walking into the Acompora's home for the first time, he spotted lacrosse gear propped up against the wall next to the door. Oliver asked Karen whether they belonged to Louis. "Yes," she said. "We just can't move them. We don't want to move them."
"You know, my world sort of crashed a little bit at that point," Oliver says. "It could just as easily have been me sitting there talking about how one of my kids died. It really made it personal for me." Oliver remembers Karen then asking him whether NOCSAE could develop a standard to prevent commotio cordis. "I think it's doable," Oliver told her at the time. "Our normal standards development process takes about two years."
It took 17 years. "It wasn't an easy thing," Oliver now admits. "But nothing worth doing is usually easy."
"When we first started, we didn't really know what caused commotio cordis," he explains. So, Karen and John launched the Louis K. Acompora Foundation, which John estimates has now raised more than $2 million. They gave some of that money to NOCSAE and Dr. Link to start finding answers. "She really wanted to understand what had happened," Link says of Karen. "To do anything she could to keep it from happening to other kids."
Dr. Link's research would find commotio cordis most likely occurs when a ball travels 30-50 miles per hour, roughly the same speed as a baseball thrown by an average teenager. Using NOCSAE money, two of Link's colleagues at Tufts, Dr. Baron Maron and Dr. Mark Estes, discovered 95 percent of victims were teenage boys. Doctors still don't know why. Link says it may be girls have more breast tissue or their hearts simply react differently. But they do know it rarely happens past the age of 25, when adult rib cages harden and can no longer bend toward the heart.
Half of the victims were participating in organized sports, most often involving a hard ball or puck, like baseball, softball, lacrosse or hockey. "Soft balls" like soccer, volleyball and football were rarely involved. But it still happened in those sports when a player collided with something, typically a goal post or part of another player's body, such as an elbow or a helmeted head.
But researchers found commotio cordis can also happen when kids are just goofing around, punching or kicking each other. Documented examples include hits from a rebounding playground swing, a hollow plastic bat, a snowball and even a sledding saucer.
Today, Link says commotio cordis is the second-leading cause of sudden death in youth sports, with one medical study declaring it "the single, most common cause of traumatic death in youth baseball." Only hypertrophic cardiomyopathy, a genetic condition that causes the heart walls to thicken, kills more children. Link says he typically documents between 10 to 20 cases a year, but he believes that number reflects underreporting. He has a video of a high school lacrosse game where, at first glance, it looks as if a teenage defenseman trips and falls during the game. But Link then slows the video and points to the attacker's lacrosse stick striking the defenseman's chest. "Unless you had that video," he says, "you would have never seen the impact to the left chest."
"The only way we hear about a case is if someone tells us or if it makes the newspaper," Link explains. He worries cases are misclassified as "natural causes" because coroners and medical examiners might miss it entirely when conducting an autopsy. "When they hear of a kid dying in sports, they're going to do an autopsy looking for hypertrophic cardiomyopathy. And because with commotio the heart is normal, the autopsy's going be normal, and I think that some of them won't recognize it."
Louis was wearing a standard chest protector when he died. But experts say these thick and sturdy barriers made for lacrosse goalies, along with the typical gear worn by baseball catchers and hockey goalies, do not protect a child from commotio cordis. Outside the Lines found even specialized "heart guards" can't pass NOCSAE's new commotio cordis standard. Parents, the experts say, are just wasting their money on false promises.
The specialized "heart guards" and "chest guards" are easy to find for sale online, with some specifically citing commotio cordis in their advertising. Outside the Lines purchased roughly a dozen, ranging in cost from $25 to more than $125. Most look like compression shirts with extra padding or hard plastic sewn into the fabric. One, for example, claims it is an "important piece of equipment that can give parents and coaches the peace of mind that their player's hearts will be protected every game," while another promises to "build player confidence while reducing the possibility of injury or death!"
Until this year, there hasn't been a way to test those claims. But using money from NOCSAE and the Acompora Memorial Foundation, Dr. Link has developed a biomechanical model that replicates the conditions under which commotio occurs and can test whether a heart guard or chest protector can actually prevent it.
"It's the first time in my experience where we've gone from knowing nothing about an injury to having a standard, that if equipment meets that standard, will in fact eliminate that death," Oliver says. "That's a really rare circumstance."
For the test, an air cannon shoots a ball at just the right speed into a "mechanical surrogate," where internal sensors precisely measure the force of the ball. So far, nothing has passed NOCSAE's chest protector standard. Meaning, there are currently no heart or chest guards on the market that can prove they can prevent commotio cordis.
Link says many of the devices don't even cover the right spot. The majority cover the center of the sternum, at the top of the chest just below the neck. But Dr. Link says the heart is located farther left, near the bottom of the rib cage, closer to the belly than the neck. "Make a fist with your left hand," he instructs. "That's roughly the size of your heart. Now place the bottom of your fist on the very bottom left rib" with your thumb pointing toward your left nipple. "That's where your heart is."
"They just make those false claims," Karen says about the devices that can't pass the NOCSAE standard. They promise false security to parents, she says, because parents will think, "'My child's wearing that particular chest protector, so everything's going to be fine.' And that's not true. It was such a lie."
Video of commotio cordis is rare. Dr. Link has tracked down just five examples, including a video of Olympian and NHL Hall of Fame defenseman Chris Pronger in the 1998 Stanley Cup playoffs taking a slap shot to his chest. Pronger, who was 23 at the time, takes two strides before falling forward onto the ice. Pronger's eyes roll back in his head and reports from the time indicate he lost consciousness for about 20-30 seconds before his heart bounced back into its normal rhythm. Link says both Pronger's age and his heart's ability to restart on its own make his case extremely unusual.
But there's another video that sat untouched for 13 years in a basement in Bethesda, Maryland, that no one, not even Link, had seen before. Mario and Deborah Boiardi have never watched the DVD of their son's last game. But they are now letting Outside the Lines share it for the first time because they want others to know what they didn't know then.
In 2004, George Boiardi was at the top of his game. The 22-year-old senior was co-captain of the Cornell men's lacrosse team, playing at the highest level of his sport. With less than three minutes left in the game, the video shows a Binghamton University player taking a shot on goal. As a defenseman, Boiardi runs to defend his goal, taking the shot into his left chest. Boiardi at first tries to keep playing, taking 13 steps before suddenly falling backward, arms and legs outstretched on the field in a spread-eagle position, his lacrosse stick still clutched in his hand.
"It was the highest profile of commotio cordis that we had seen in the sport," U.S. Lacrosse CEO Steve Stenersen says. "I think that alone was enough to really propel and shock people into paying attention to this rare but devastating injury."
"Prior to George's passing, there were coaching techniques that encouraged non-chest-protected players to step in front of the ball to block the shot," Stenersen says. "'To eat the ball' was the terminology at the time." Defensemen would also creep in behind the goalie, close to the pipes, to "give shooters less of a look at an open goal." Both techniques, Stenersen says, were instantly banned.
U.S. Lacrosse is also moving away from balls made of India rubber, which can become 50 percent denser in just six months in some weather conditions. Stenersen says the sport's governing body is working with NOCSAE to test materials "made of synthetics that hold their properties longer."
While Stenersen says players get hit hundreds of thousands of times without a problem, he explains "parents need to understand the catastrophic potential of this injury." If a company can develop a heart guard or chest protector that can pass the new NOCSAE standard, Stenersen promises U.S. Lacrosse will mandate all high school and college goalies be required to wear it. "That's the one position on the field in which we have a requirement currently," he says. "However, as we know, commotio cordis episodes have happened in non-goalie players as well, field players, some of whom have died. So, the next stop is to see how quickly we can work with the industry to get them to develop a piece of chest protection that would be applicable to field players."
Until that miracle product actually passes the standard, Stenersen says the best solution is the one first proposed by the Acompora family. "They've saved dozens and dozens and dozens of lives," Stenersen says. "They're an unstoppable force."
The walls of the Acomporas' basement are covered with mementos of Louis. They've moved his stick and his helmet onto the shelves here. They've framed his lacrosse jersey and newspaper clippings written about him. There's even a stained-glass window of a lacrosse goalie watching over it all.
But there's also a photo of John and Karen standing near then-New York Gov. George Pataki as he signs Louis' Law. After Dr. Link told them what had really killed their son, Karen and John quickly realized an automated external defibrillator could have saved his life. "What an AED does is actually stop the heart, which is in chaotic rhythm, that ventricular fibrillation," Karen explains. "The AED actually puts the heart at rest in the hopes that it will restart in a normal beating pattern. It's kind of like, you know, if the computer's haywire, you turn it off and hope it heals itself. And an AED actually turns the heart off in the hopes that it will restart again in a normal rhythm."
But when Louis died, Karen says, AEDs were rarely being used outside of hospitals. She remembers the only publicly available ones were inside Las Vegas casinos, where they were being tested as part of a public health study. "The American Heart Association was not behind us," she recalls. "Now they are, of course. But back then, they hadn't put their resources and their time into evaluating it long enough." Many health experts didn't think AEDs should be used on children, let alone made available to the general public. "They did not believe that the average layperson would be responsible enough to save someone's life."
Karen says she started small, convincing her local county government to put AEDs in all of its police cars. The Acomporas then pushed for Louis' Law, which requires an AED in all of New York's public school buildings.
Karen now wants an AED on every athletic field because you only get five minutes to bring a child back. She says you can't wait for paramedics like she did. "Louis passed on the athletic field," she says. "He had absolutely no chance. None. And we were only a quarter of a mile away from a hospital."
After George Boiardi's death, Cornell University installed more than 170 AEDs throughout its campus. Every athletic trainer has their own device to carry wherever they go. U.S. Lacrosse offers grants to grassroots teams to help them buy the devices. "I have to say U.S. Lacrosse is amazing," Karen says. "There's such a brotherhood involved in lacrosse. They took it very seriously."
But other sports, such as baseball, have been much slower to act, according to Karen. She says there are still 30 states that don't mandate AEDs on school grounds. And don't get her started on youth athletic organizations. "You have to hit them over the head with a frying pan," she says. "They just don't get it."
An AED costs about $1,300, an amount Karen thinks every rec league can afford with little effort. "Raise registration. Don't have new fancy T-shirts this year. Fundraise. Make it a priority that your coaches are trained in CPR and how to use an AED."
To play in the annual Louis Acompora Lacrosse Jamboree, every coach and every player must go to a tent to learn CPR and how to use an AED. The devices are so easy to use, Karen insists, they tell you what to do once you hit the "on" button. They won't shock someone who doesn't need it. And, as she points out, you can't hurt someone who is already dead. With medical studies showing an average sixth-grader can safely deploy an AED in roughly the same amount of time as an EMT, the Acomporas make sure even their littlest players participate in the training.
Some of the adults teaching the classes in the tent were themselves revived by an AED machine placed in their gym or on a field by the Acompora Memorial Foundation. Karen says nearly half of their "saves" have been older adults working out or sitting in the stands during a game.
Karen and John are in the middle of training some of the high school players when word comes that he's here. The boy with the blue eyes. The boy who died in the batting cage.
Jack Crowley has arrived.
"It's a 7-year-old baseball game. It's not going to be the most exciting thing." Jack Crowley smirks as he remembers how, two years ago, he finally gave up on the 7-Eleven idea and agreed to hit some balls in the batting cage with his brother Aidan. "I was just picking up the ball and throwing at him. And he was hitting it. Just kind of screwing around, talking to each other. Heckling each other a little bit."
Jack was maybe 30 feet from his brother. He had been pitching from behind a screen inside the batting cage. But they had run out of baseballs. "And there was one, like, two feet to my right that he had hit and it kind of rolled toward me. I leaned down to pick it up and I took a step up and I just tossed it," Jack explains. "He hit the ball, hit it hard. Hit it well. You gotta give him credit."
Jack tried to get out of the way by turning sideways, exposing his left side, where the ball caught him in that critical spot at the bottom of his rib cage. "It hurts a little bit," Jack remembers. "I start to walk it off. And then 15 seconds later, maybe not even that, I couldn't get a breath in at all. My lungs couldn't get air in. It was like there was a hard candy in my throat."
He vaguely recalls his brother's face. "He was looking at me like, 'Stop playing around.' He thought I was screwing around." But Jack couldn't get any air. His diaphragm wouldn't expand. "I got dizzy and went down to my knees. And I don't remember anything after that."
A friend of Aidan's saw Jack collapse and ran over to the nearby Little League game, yelling for help. Nancy Crowley looked to where the friend pointed and saw Jack lying on the ground. "He did not look right. It didn't look like a normal fall. We all ran over there."
Nancy immediately saw Jack had turf burn all over his face, having been unable to brace himself as he fell because he had lost consciousness. She at first thought he had a head injury. "His face was very bloody and blue. Like unnaturally blue." She says she knew in that moment that her son was dying. "His eyes were open, but he was not seeing you. His eyes were just fixed and staring."
"Everyone was very panicked. Everybody came running very quickly," Nancy says. "He was quickly surrounded. He was still in the batting cage, but the whole batting cage was surrounded, like, you're kind of on stage."
She remembers Aidan's friend, the one who had gone to get help, tried to tell the adults it wasn't Jack's head. Jack didn't get hit in the head. "He was hit in the chest," Nancy remembers the friend saying. "But you still don't think that stops a person's heart." That's when Nancy started begging her son to wake up. "Come back. Mom's here. Please talk to me. You're OK. I got you. You're fine. Come back to me."
Another parent, an off-duty police officer, was standing in line at a nearby concession stand when he heard the commotion at the batting cage. "His instinct was to grab the AED that he knew was there" because of his training, Nancy says. "He came over and said, 'Do you guys need this?'" A doctor grabbed it. Another parent, a nurse, grabbed Nancy and forced her to turn away as they tore open Jack's shirt, getting ready to shock him with the AED. "She's a good person," Nancy says. "She didn't want me to see that."
"First thing I remember when I woke up was I felt like I was in bed," Jack says. "Waking up for a morning going to school. That's what I remember it feeling like. And my mom was like, 'Wake up.' And I was like, 'Let me go back to sleep.' I wanted to go back to sleep because it was the best sleep I'd ever had."
"Probably within 15 seconds, he just started making noises in his throat. Like he was trying to talk," Nancy says. But Jack couldn't see. "It was pitch black. But I could hear everybody talking." Within a minute, Nancy says, as his color started to come back. "You could see his personality coming back."
"All of a sudden, I could start to see," Jack explains. "And it came fuzzy at first and then I could see pretty clearly." Nancy remembers he asked, "What is going on?" before telling everyone, "I'm all right now. I want to go home."
The entire episode, from Jack's collapse until the AED shock, took roughly three minutes.
"He asked to go to McDonald's on the way to the hospital in the ambulance." Nancy still marvels at her son's recovery. "He's back to his normal life. He has no residual problems. He's back playing baseball."
But it was only later, when Nancy began to ask about who put the AED in the concession stand, that she truly understood how lucky they were. "There was an AED there because another mother, Karen Acompora, pushed for them when she lost her son."
As she talked about what she calls "the worst day in my life," Nancy never cried. Not when she thought about her son's eyes. Not when she remembered her son dying. Only when she says Karen's name aloud for the first time does she tear up. "I felt that horrible pain of actually losing a child for a couple of minutes," she explains. "Just to go through, you know, the rest of your life feeling like that. It's unimaginable to me."
"What happened to Louis was for the good of boys like Jack Crowley," Karen says. "Louis has saved nearly 100 people. Because if it wasn't for Louis, those people wouldn't be alive. That's the truth."
For his part, Jack says he now has an unexplainable bond with a boy he has never known. "I wish that he could still be here," Jack says. "But if he was, I probably wouldn't be."
On a bright, sunny Saturday, John and Karen are back in the stands to watch their 8-year-old grandson, Louis, play in his first lacrosse tournament. "It's so surreal," Karen confesses. "If you would've said to me that it was the way it was going to be, 17 years later, that my grandson Louis was going to be playing at Louis' Jamboree, I never would have believed you."
Little Louis is the smallest player on the field. He wears No. 12, just like his uncle. But he's not playing goalie. They just can't. Instead, he's up front and scores three goals in the first quarter. His grandparents cheer louder than anyone else on the field, discovering joy again in the sport that killed their son.
Karen admits she doesn't know what to tell parents who might be afraid to put their child on a field. "I struggle with that all the time. I really do." All she knows, she says, is "As a parent, you have to make sure that you've done everything." For her, that means learning CPR and always having an AED nearby.
As word spreads that Jack Crowley and his mother have arrived, Karen and John go to the parking lot to meet them. They hug him close before leading him toward a stage under the scoreboard bearing Louis' name. Jack has written a speech about what happened to him two years ago, when he was the same age as Louis. About how the same thing happened to him, but why his story has a completely different ending. Addressing a crowd made up of players, parents and other survivors like him, he says, "I am truly grateful for the Louis Acompora Memorial Foundation and all that they do. I and many others owe our lives to them." He then tells Karen and John, "Thank you from my still-beating heart."