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Rapid Competent Medical Response: Effect on Damar Hamlin // COVID// Drug Anaphylaxis // Death Rates

What we have all learned by hearing the story in the news of Damar Hamlin, is that he is a remarkable young man: strong family values; generosity with his Toys for children charity... if we only had more people like Damar Hamlin. But this blog is not about his personal qualities.

Being a Safety expert in Radiology, I have thought long and hard on death rates from contrast agents in Radiology, iodine and gadolinium agents, but also death rates in general in medicine, and death rates and causes in otherwise health young adults.. What I was most struck by with his story is:

"Wow, that was amazing the incredibly fast and competent medical care that he received in the middle of a football field, surrounded by lots of players, and in a stadium of 10s of thousands of noisy fans. That was one of the most amazing medical events I have ever seen. The response rate was 10 seconds, incredible. And they did the right thing, also fantastic.". Essentially everyone else would have died, or at best been permanently disabled, because no one can get a 10 second competent medical response.

Many people heard for the first time the words commotio cordis. (commotion in the heart). Many things are very similar to each other: the heart has a complex electrical system with electrical pulse initiates in the SA node, to stimulate atrial contraction, then progresses to the AV node, to stimulate ventricular contraction and passes along the bundles of His to orchestrate orderly ventricle contraction. Sounds sort of like the complexity of the immune system. As with the immune system, it is easy to imagine how a number of things can go wrong, especially since there can be a number of congenital anomalies of these electrical channels, and myocardium, causing a number of cardiac arrhythmias, and even without congenital anomalies, variations of serum electrolytes. Very easy to imagine just a fast heart rate change to ventricular tachycardia - ventricular fibrillation and death. More or less the same story as with the immune system.

Whenever I have heard the story of a healthy adult dying in a surprising fashion, exercising at a football or other sporting event, over-exercising with military training - the first thing I think of is- fast heart rate > ventricular fibrillation > death. Maybe 1 in 1 million this type of event occurs. There is all sorts of head scratching- what do we have to do so this never happens again..... I know this is a 1 in 1 million event- I think we need to focus on 1 in 1,000 events, because essentially anything can happen from any event at a rate of 1 in 1 million. Sorry. But this does not mean that wisdom-sense should be used.

1 in 2 million children will have a catastrophic neurodegenerative disease secondary to a measles vaccine. Measles is highly contagious, 1 in 100 with measles get serious disease and perhaps 1 in 1,000 will die... But this not to mean ignore the severe reactions to vaccine - what is critical is to study collectively the individuals who develop this reaction, and see what the difference is in their immune system and genetics from 'normals'; to avoid individuals with that combination of genetics/immune system from getting the measles vaccine. If that is not done (which is the present situation), then it gives credence to those who don't want their children to get the vaccine.

Reported death rate from acute hypersensitivity reactions: catastrophic anaphylactoid reaction, has varied, and primarily based on assumption-laden data. Initial death rates for GBCAs (which was primarily Magnevist at the time) was 1 in 3 million, and this was contrasted with the death rate of 1 in 300,000 with iodine contrast.. as reason to prefer MRI, and MRI contrast over CT and CT contrast. Over the years though this death rate has ended up to being estimated at 1 in 300,000 for gadolinium contrast and 1 in 150,000 for iodine contrast. The difficulty of coming up with these numbers is that many people are sick, and some extremely sick, before getting these studies... so is the underlying disease the primary cause of death? Other times in the commotion of emergency management of individuals with systemic collapse undergoing imaging, some individuals who have been attributed to a contrast reaction, had this resuscitation prior to contrast administration.

One thing I have learned to distill in complex medical situations and complex data: to tease out if certain events actually have occurred. In elderly and very sick people with very brittle health, it is very difficult to assign mismanagement for dire outcomes. I generally do not do that myself. However it is true that young healthy individuals can die from catastrophic anaphylactoid reactions. These are the tragedies. Old people dying from a contrast reaction, I guess now I include myself in that group, is sad, but not tragic. The critical thing is to prevent true tragedies from occurring. Note one can replace where I have written 'acute hypersensitivity reaction' with 'COVID'.

Death rate in young healthy individuals with contrast agent hypersensitivity reactions (COVID as well) are the true tragedies. Most of this stem from the lack of rapid, competent, medical response (RCMR). Most often RCMR is lacking with young healthy adults because it is assumed when they react to a contrast agent, that they are young and healthy they will be just fine (the medical equivalent of walking it off), and health care workers don't respond at all with emergency support, or when it is too late. Often just a jab from an epipen will have prevented that death.

In general probably the great majority or all deaths from contrast agents in young healthy adults (and children) are avoidable if there is the kind of RCMR that Damar benefitted from. Unfortunately though in the real world this is just not possible. I think an easy medical understanding is this: just because a person is young and healthy does not mean they won't die from an imaging contrast reaction - in fact, as with GDD, since their immune system is likely fully intact, they are much more likely to be able to mount a fatal cytokine storm reaction, than either old sick people or young children. So pay attention to young people who appear to be struggling significantly after a contrast injection.... they may just die if you don't intercede.

So my estimate of death rate in young healthy people from contrast agents, and COVID, is in the range of 1 in 2 million for contrast agents and 1 in 100,000 for COVID, but if there was RCMR those numbers should be 0.... But that may be a utopian pipe dream and would be enormously expensive.

The best use of health care dollars: prevention and early interruption of obesity. Our present health care system is focused on disease management. It should be focused on disease prevention, health management, and early diagnosis and treatment focused on cure. Mandatory health and wellness education K- 12 emphasizing diet, physical activity - focused on what each child wants to do (within reason), and not running a marathon for all children, or having them climb a rope up towards the ceiling. Mandatory education should be: 1. health and wellness, and physical activity; 2. Communication: english (in english-speaking countries- native language in other countries) language, speaking, reading, transcription, and creation. 3. practical science including computers. Everything else maybe is somewhat worthless and some things foolish and damaging. Also of value a class that includes treating others as you would have them treat you: understanding, compassion, empathy, and caring, this class could be called Social Studies.

Regarding RCMR, that is terrific that the NFL can afford it, and most of us are extremely happy for Damar, who is a wonderful young man and should be a positive influence for many young people. For the rest of us, somehow more wisdom-sense is needed in the average health care worker - maybe the starting point: Physicians pay attention to what is happening with the patient (Boerhaave) and listen to them: Doctors, listen to your patients, they are telling you the diagnosis (Sir William Osler). Bad events and outcomes have to be analyzed and prioritized based on how likely they are too occur.... this does not excuse ignorance and disrespecting patients.

Richard Semelka, MD

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