A couple of weeks ago, my sister texted me that my 26-year-old nephew Justin was complaining that his chest hurt every time he breathed in. Justin is a healthy, athletic guy who played soccer throughout high school and volleyball in college. More recently, while living back home job hunting after finishing a master’s degree in business, his sporting activities have been of the online variety. As he did in all of his sports, Justin excels at video games. He spends hours competing and socializing virtually with friends he’s made from all over the world since gaming has exploded in the wake of the pandemic. And while Justin has been encouraged by his parents to do more physical activity at this in-between time of his life, there was no real concern that the hours spent happily engaged in community play could lead to a dangerous medical condition. And although I took his symptoms seriously since Justin rarely complains, I wasn’t initially worried either.
As an internal medicine physician, as is the case for most doctors, I’m often consulted for familial medical questions. My response to my sister was that Justin could have pneumonitis – something irritating his lungs like an allergy or infection. Or perhaps, a pneumothorax or partial lung collapse, which can happen spontaneously to young people especially. At urgent care, an X-ray and EKG were read as normal. He went home with Advil and Tylenol for what was likely a musculoskeletal strain, or “pleurisy.”
A day or so after that visit, my sister texted: “Justin is crying because the pain is so bad. I don’t know what to do.” We decided he should go to the emergency room. There they found some slightly elevated inflammatory markers (“non-specific” signs, as we call them in medicine) and something on the CT scan, which they read as pneumonia. This struck me as odd since he didn’t have a fever or cough, but he went home with antibiotics, and what seemed like an explanation.
The next day my sister texted again: “The ER called Justin’s doctor this morning. They are now reading the scan as a possible blood clot in his lung.”
How could this be? A blood clot? A pulmonary embolism? This was extraordinarily dangerous – potentially fatal. I needed to convey this to my sister without terrifying her. I decided to tell her the truth: “Karen, if he was my son, I’d take him back to the ER. Now.”
On the way to the emergency room, they called Justin’s doctor who redirected them to the lab and to the pharmacy to get started on blood thinners as an outpatient.
The risk of developing life-threatening blood clots from long plane flights or car rides is well known. On overseas flights, crews are known to encourage patrons to get up and stretch. Some in-flight magazines also remind of the risk and encourage hydration and leg exercises. More recently, Serena Williams’ terrifying ordeal with a pulmonary embolism highlighted the connection between pregnancy and blood clots. But thromboembolism and video games? We don’t hear much about that. It makes sense, of course, that hours spent sitting, immersed in vibrant and stimulating worlds that keep players so rapt and engaged that they lose track of time, would contribute to exactly the same risks as any other kind of prolonged inactivity. But why wouldn’t this be more widely discussed – in the media, by the gaming companies, by politicians, by parents? By doctors?
I’ve been a physician for 25 years, many of those spent caring for seriously ill patients in the hospital, and I’ve never once heard gaming specifically discussed as a risk factor for pulmonary embolism. In fact, the day Justin was diagnosed, I called my doctor friends – all well-respected in their fields: a pulmonologist, an emergency room physician, my boss who practices internal medicine, and two hematologists. While they all entertained the idea that the long hours scrunched into a chair attending to a screen might put one at risk for thrombosis, none seemed to latch onto the idea; although one hematologist ventured, “I’ve seen this a couple of times in air traffic controllers,” but I sensed it felt like a long shot. Perhaps it is our collective sense of the invincibility of the young since the average age of a gamer is 37. But I discovered that catastrophic outcomes have occurred in those on the lower end of this age spectrum.
One case report from Korea in 2004 claims to be the first case of fatal “thrombosis” in a 24-year-old who was spending hours playing games on a computer. The author writes: “Our modern society is very sensitive about computer viruses and other dangers to computers, computer programs, and data, yet not to possible human injury.” In 2013, a case was reported from New Zealand of a 31-year-old gamer diagnosed with an “extensive left leg deep venous thrombosis” after using PlayStation for eight hours per day for four days in a row. In 2020 there was a review of published reports on “gamer’s thrombosis.” Many of the cases were reported outside the U.S., and more study was recommended. But the conclusion was clear that gaming should be understood as a risk factor for thromboembolic disease (Rambaran). There’s also a smattering of other medical cases and media reports of gamers stricken, or deceased, from deep vein thrombosis or pulmonary embolism. One particularly heartbreaking website and campaign StandUpForLouis – and prevent a tragedy | DVT: know the symptoms, started by a family who lost their son this way, provides education for schools, and advice for those who sit at games and computers for a long time. Through email, I corresponded with the father who was open about his life-shattering experience and loss: “I don’t blame the games Louis played,” he wrote to me, “he wasn’t doing anything wrong; we all just didn’t know the health risks or symptoms when they developed. We thought he had pulled a muscle or something in his leg and just needed to get more exercise.”
Justin got his medication, but he wasn’t able to schedule the confirmatory CT angiogram until the next day. Thankfully, he started the blood thinner. “He’s still in pain,” my sister texted later that night. I was somewhat comforted by the knowledge that he was on medication. But the next morning my sister called from the radiology suite. Her voice was steady but with an underlying tension that was threatening to snap: “He has new clots. They are sending him back to the ER.”
I felt this like a gut punch. I knew Justin had already started on treatment but just how anticoagulated was he in that first 24 hours when it seemed new clots were being thrown to his lungs? I knew the onset of action of the medication was a few hours, but everyone’s chemistry is different. We’d entered that familiar place in medicine where you’re forced to deal with the uncertainty inherent in living with the unique peculiarity of our individual bodies. We had statistics but we also had the big unknown: Was Justin safe? It was impossible to be sure.
Justin’s vitals remained stable overnight. An echocardiogram was done to be sure his heart wasn’t strained by a large clot, and to rule out the possibility that the clot had originated in the heart. There was no strain and no blood clot. Also, none of the blood work done at the outside lab or in the hospital showed that Justin had any inherent tendency to form thrombi. The ultrasound of his legs also didn’t show where it had originated. The next day, it was determined he was stable enough to go home. And by the process of elimination, everyone accepted that marathon gaming sessions were the most likely cause of Justin’s pulmonary emboli.
It’s terribly traumatic to get a life-threatening diagnosis. It leaves you with the sense that your body has betrayed you. I should know. I had a brain hemorrhage at age forty-five. And although I too fully recovered, the sense that some switch could flip at any time, causing excruciating pain or incapacity, has never left me. I was saddened that my nephew learned this lesson about our fraught bodies at such a young age. But I was also grateful his warning sign didn’t lead to the unthinkable outcome that haunted my sister and me the whole time.
As a doctor, I felt a duty to tell Justin’s story – to raise awareness for gamers and their doctors. As someone who spent her high school evenings in dance class and pre-med days in the 1990s teaching aerobics at a health club in New York, I’m secretly hoping the companies that sell these products can incorporate hourly pauses for dance parties or step aerobics into their games.
At the very least, I’d love to see a giant red label that must be read before the product can be used, a “hard stop” as we have in the electronic health record, requiring acknowledgment before you can move on with your work.
I’d also like to implore gaming companies, and perhaps lawmakers, to insist that this warning sticker be shaped like a heart – to remind us of just how much is at stake when someone we love is in danger of dying.
Eve Makoff is an internal medicine physician.
