Bolton was wearing black.
Few who were at that evening's F.A. Cup quarterfinal match five years ago between Bolton Wanderers and Tottenham Hotspur remember that better than head Bolton physiotherapist Andy Mitchell.
Under a darkening sky and against the dark backdrop of the stands at London's White Hart Lane, Mitchell had a difficult time seeing his team's players. He told himself to stay especially focused: his job was to monitor the players, not watch the ball.
So, when 41 minutes into the first half, Fabrice Muamba, Bolton's 23-year-old Zaire-born midfielder, collapsed near the center circle, yards away from the action, Mitchell saw it all unfold.
"He went down in a sort of slow-motion, face-forward way, which was just completely not right," Mitchell recalled in a phone interview. "My instincts were telling me something was seriously wrong here."
Mitchell didn't wait for referee Howard Webb to give a signal to the bench, as the rules normally called for. He just ran.
Five years ago today, on March 17, 2012, Fabrice Muamba's heart stopped beating for 78 minutes. It was perhaps the most public cardiac arrest in history, as well as one with the most miraculous ending: Muamba may no longer be able to play professional soccer, but he is alive. And, perhaps most astonishing of all, he did not suffer any significant brain damage.
Doctors aren't sure why Muamba's heart stopped. A common cause of similar incidents is hypertrophic cardiomyopathy, a condition (predominantly inherited) that affects an estimated 1 in 500 people, and is the leading cause of sudden cardiac death among young athletes. HCM, as it is known, causes the abnormal thickening of the heart muscle. Unable to hold as much blood, the heart can struggle to pump out enough blood during exercise. Muamba has been widely reported to have had HCM. Still, Muamba's former team physician Dr. Jonathan Tobin thinks Muamba's prior heart screenings would have picked up the condition.
Collapses like Muamba's are rare, but by no means unheard of. Since Muamba's scare, more than a dozen professional soccer players have died after suffering suspected cardiac arrests in leagues around the world, including Italy's Serie B and the top league in Romania.
One reason for all of these deaths is that HCM is notoriously difficult to detect. Players in the Premier League are scanned for it and other heart conditions every year, but no scan ever showed that Muamba had an abnormal heart condition. And it's too late to figure out now: Since the cardiac arrest, Muamba's heart has undergone too many changes for doctors to make a conclusive diagnosis that would explain why the young man's heart stopped that night in North London.
When he went down, the Spurs supporters' first reaction was to jeer. Muamba, after all, was a product of their rival Arsenal's youth academy and most of the fans hadn't seen the unnatural way in which he had fallen. Once the fans noticed that many players had their heads in their hands, it didn't take long for the more than 30,000 in attendance to go quiet. Soon they united with the Bolton fans in singing Muamba's name, over and over.
"It was almost as if the crowd was willing him to stand up," recalled Chris Knight, a Tottenham fan who was at the game.
As it became clear that Muamba still wasn't moving, the chants began to dissipate. Fans tried to text friends or check social media for information, but cell phone signals inside the stadium were notoriously poor. Those who were able to get data would have seen that #Pray4Muamba was already trending on Twitter.
"Everyone was just standing there in stunned silence," recalled another Tottenham fan, Alan O'Brien, who had brought his 14-year-old and 8-year-old sons to the game. By that time, O'Brien's younger son, was sitting down and playing with his Game Boy, his father and older brother trying to prevent him from witnessing such a traumatic event.
Mitchell was the first to reach Muamba on the field, but it didn't take long for Bolton's Dr. Jonathan Tobin and Tottenham's Dr. Shabaaz Mughal to arrive. The three immediately recognized the severity of the situation.
Muamba was face-down and gasping, but none of his movements seemed voluntary. Mughal flipped him on his back and began chest compressions while Tobin began administering mouth-to-mouth. Sixty-seven seconds after hitting the ground, Muamba was receiving CPR. Seventy-four seconds after that—a total of just two minutes and 21 seconds after Muamba's collapse—doctors had placed a defibrillator on his chest and were trying to jolt his heart awake.
"If somebody had a cardiac arrest in a hospital they probably wouldn't get a defib in two minutes," Mitchell said. "It was a really, really speedy operation that was performed on Fabrice."
After quickly getting Muamba onto a stretcher and into an ambulance, Tobin got into the back of the vehicle, where he was joined by paramedic staff and Dr. Andrew Deaner, a cardiologist who who was attending the game as a fan but had been able to convince a steward to let him join the doctors on the field. The ambulance headed to the London Chest Hospital and Deaner, who worked there, had already made sure his staff knew to prepare for Muamba's arrival.
The circumstances broke just right for Muamba and his doctors throughout the process. But that isn't always enough. Although the medical team's actions may have been quick and ultimately life-saving, at the time the situation appeared grim.
While Tobin had gone into the ambulance, Mitchell had taken on a spokesperson role to keep referee Howard Webb and Bolton manager Owen Coyle up to speed.
"I told the manager that I couldn't see how we could say anything positive," Mitchell said. "It was that desperate. The manager told the rest of the players in the dressing room and nobody said a word. Everybody just sat there." Many would soon be in tears over their popular teammate, who was known for his ever-present smile and his constant jokes.
After having continued the chest compressions in the ambulance and handing off Muamba to Deaner and the other cardiologists at the London Chest Hospital within 48 minutes, Tobin also broke down.
"My back hit the wall and I just slid down the wall and broke into tears," Tobin said. "I really couldn't see any recovery being possible at that point. The stress and the pressure of dealing with that and 35,000 people chanting his name, it was just astonishing. I think all of that emotion came pouring out when I handed him off."
At that time, Muamba was, medically speaking, dead. He had received a total of 15 shocks before he reached the hospital and would receive another 15 after his arrival, but none had brought him back. Yet despite the dire situation, the doctors continued to have a machine perform CPR. And then, as Deaner and others were conducting yet another test, Muamba's heart started to beat. He was placed in a medically induced coma for the next day, and then as his body temperature slowly rose, Muamba moved his head to the side and woke up.
In his 2012 autobiography, I'm Still Standing, Muamba recalls opening his eyes and seeing his fiancee Shauna by his bedside. Confused, he asked where their 3-year-old son was.
"Where is Josh?" he whispered.
When turning 16, each soccer player who is part of a club in England's top four tiers fills out a questionnaire and receives an electrocardiogram (ECG), a test that checks for any abnormal heart rhythms. Ninety percent of people diagnosed with HCM will have an abnormal heart tracing, says Dr. Lynne Millar, a cardiology registrar at King George Hospital outside of London.
Even when players pass the ECG, they then receive an echocardiogram, a test involving an ultrasound of the heart. Most clubs go through the process again when a player turns 21. In the Premier League, just about every club repeats the process every pre-season, in addition to what Tobin called a "barrage" of blood tests. The scans are not cheap, but Premier League teams are so flush with cash that it is not a concern, Tobin says.
Five years ago, about ten hours after Muamba collapsed, and upon finally getting to his hotel room, Tobin began to wonder if he was partially to blame for Muamba's collapse. Had he and the rest of club's medical staff forgotten to conduct the annual tests on Muamba heart during the previous summer? Muamba, after all, had been away in Denmark with England's under-21 national team at the 2011 European U-21 Championship. Was it possible he had slipped through the cracks?
"I was in actual panic, thinking 'Oh crap, had we actually scanned Fab?,'" Tobin recalled.
But records show Muamba had been scanned. And the results did not indicate anything troubling, a fact that has been confirmed by several cardiologists who have since re-read the scan, Tobin said.
Detecting HCM among athletes of African descent can be particularly difficult, Millar says. A 2008 article published by the Journal of the American College of Cardiology found that athletes of African descent tend to have slightly thicker heart muscles than Caucasian athletes do. That difference can make it difficult for doctors to discern whether or not a black athlete's thickened heart muscle is something to be concerned about, Millar said.
Over the past five years, there have been no significant breakthroughs in terms of how to detect HCM in professional athletes. Clubs still conduct the same tests each year, although it is unknown how many players have had their careers ended—or lives saved—by the tests.
Tobin says the value of the scans is debatable, bringing up the example of an unidentified 17-year-old Premier League player who he says was told he could not play anymore because doctors found an anomaly in his heart. The rest of the player's family was scanned for the hereditary condition and it turned out that the player's father had the anomaly too. Ironically, the teenager's father had been an Olympic athlete.
"The kid came back and said 'Look, I'll take the risk. It's my heart,'" Tobin said. "But the club said that for insurance purposes they couldn't possibly allow that to happen. The kid eventually got turned down by several clubs and never had a career. If I was that kid and I was allowed to choose whether or not to have a screening and you knew the possible outcomes, would you still have had it done?"
In his 13 years of conducting athlete screenings, Tobin said he has advised one 16-year-old not to play soccer because of a heart abnormality, but "he was a fringe player at a fringe club," Tobin said.
One effect of the Muamba match has been in increasing awareness about the importance in detecting heart conditions.
In the wake of the Muamba match, campaigns grew for more young people to receive heart screenings. A British charity called Cardiac Risk in the Young (CRY) conducts ECGs on 18- to 35-year-old adults—athletes and non-athletes alike—to detect any abnormalities. The scans aren't perfect, but they can detect life-threatening conditions.
"To see someone who is seemingly at the pinnacle of health collapse and have a cardiac arrest—I think people became more aware of these particular medical conditions and more likely to seek medical attention if necessary," Millar said.
Trying to explain Muamba's recovery has continued to leave doctors stumped.
"I've heard a thousand theories," Tobin said. "Everything from Fab's spiritual belief to that ... his body was as full of oxygen as it possibly could be, to the fact that he was young and had a very compliant chest for cardiac compressions, but no one knows. It's a sheer and utter mystery."
Bolton fans show their support for Muamba the week after his heart attack. Photo: Matthew Chadwick via Wiki Commons.
One crucial factor, though, lies in how quickly Muamba was treated.
That, Tobin says, comes down to the preparation that the Premier League medical staff had gone through. Each year, all of the team doctors and medical staff receive the same thorough training regimen, meaning that each club's medical team has been taught the same approach to any conceivable emergency. That background, Tobin said, was crucial to what happened at White Hart Lane, as Tobin and Mitchell worked alongside Tottenham's medical staff, the two sides hardly having to speak to coordinate their actions.
"I'm happy to say that if any of the other Premiership doctors had been there I think the outcome would have been identical," Tobin said. "I don't think there's anything I did that wouldn't have been done by doctors in the same situation."
Tobin argues that because everything went so well, clubs across the Premier League know that they must be equally well-prepared if a similar incident happens at their stadium or their training ground.
Clubs, he said, now have extremely thorough emergency plans to include everything from how to ensure that ambulances can get out of a stadium to who knows where the key is for the gate to allow an ambulance to access a training ground.
"All these little bits and pieces are all in place and I'm not entirely sure they were in place before," Tobin said. "It set the bar so high in terms of what is possible that anything less than that would be considered a failure."
Of course, the vast majority of athletes with undiagnosed heart conditions will not have the good fortune of being treated by Premier League doctors who routinely practice treating cardiac arrests.
"Most people aren't so successful," Millar said. "The Football Association has a plan for what to do if this should happen. But if there's no bystander CPR or there's no early defibrillation, then the outcomes are much, much worse."
Tobin and Muamba still get coffee together, every once in awhile. The now-retired player has called Tobin, Deaner and two others his "guardian angels" for saving his life.
Muamba has a pacemaker and sometimes has short-term memory problems, "but there's no way anybody would notice unless you knew Fab incredibly well," said Tobin, who is now the club doctor for Fleetwood Town. "You wouldn't, in normal conversation, notice that he is any different from the Fab beforehand." Muamba did not respond to multiple interview requests for this story.
Ever the jokester, when he and Tobin meet up, Muamba likes to blame the doctor for any issues that have sprung up.
"He just gives me a hard time about everything, like how his memory issues are my fault because I didn't do my compressions well enough," Tobin said.
Tobin knows it's all in jest. He's just happy to see his friend alive and in such good health. Muamba graduated from Staffordshire University with a degree in sports journalism in 2015.
Tobin also realizes that he will probably never be in a situation that can top what he experienced five years ago.
"Having achieved that and been part of that, you never really feel driven in football to do much more than that, to be honest," Tobin said. "I got a letter from a cardiology professor who specializes in cardiac arrest resuscitation and he wrote to say that in all his career he's never heard, let alone seen anyone with a down time that long come back—not even close. That's the thing that often gets me: the coincidence between probably the most public cardiac arrest in sporting history and also the one with the most fairytale outcome. The coincidence of that is too much for anyone to believe."
About six months after collapsing, Muamba returned to White Hart Lane during halftime of a Europa League match. The crowd gave him a roaring ovation, including Alan O'Brien, the fan who had brought his two boys to that March match against Bolton. Only the elder son had accompanied his father this time, but the game served as "closure," O'Brien said, for the two of them. They had seen him fall and were now witnessing his return.
With the crowd continuing to cheer his name, Muamba tearfully walked out to the part of the field where his heart had stopped. The crowd directed him as he made his way.
"He would point and the crowd would say, 'More this way, more this way,'" O'Brien recalled.
Muamba didn't remember precisely where he fell. But Spurs fans will never forget.