It is not "Mental Health," it's the f...ing guns!

In 2020, firearm fatalities displaced motor vehicles accidents as the leading cause of death of U.S. youth (ages 1-19). We long ago dramatically reduced infectious deaths (though vaccine hesitancy threatens to upend this victory), and the “big five” have been auto accidents, firearms, cancer, suffocation and drug overdose – accidental in the youngest and intentional or accidental in teens.

Between 2000 and 2015, firearm deaths remained steady at about 10% of all youth deaths, but this has grown dramatically since, and guns caused 19% of young peoples’ deaths in 2021.

Children, of course, are not the only ones to suffer. Between 1990 and 2021, 1,110,421 Americans died as the result of gunshots: homicidal, suicidal or accidental. The death rate has roughly doubled between 2014 and 2021. Deaths disproportionally affect males: 86% of the 1.1 million deaths were men. When looking at deaths among young people, black boys are much more likely to be killed than non-Hispanic white youth. When we look at suicides, older white males are the victims more than any other group.

Comparison with similar countries emphasizes how much of an outlier we are in the U.S. An American is 30 times more likely to die by firearm than a French citizen. Not surprisingly, in France there are 15-20 privately-owned firearms per 100 population, while in the U.S. there are 120 per 100 people. Multiple studies have shown a tight correlation of numbers of guns in circulation and gun deaths. Within the U.S., states with tougher gun laws have significantly lower firearm mortality.

Certainly, social factors – mental health issues, including depression, poverty, lack of social supports – play a role, but these are not unique to Americans. Every country has its share of sociopaths, depressed people and people angry at the world, but only in America is it so easy for these people to obtain a gun.

If someone tries to kill themselves with an overdose, there is a high likelihood they will be saved and then given help. Very few of such people die of suicide. When the method chosen is a gunshot, the “success” rate is nearly 100%.

A fanatic can kill innocents with a knife (or their bare hands), but mass killings are almost always done with firearms.

Public opinion surveys consistently show that the majority of Americans support tougher gun laws, but our federal legislators seem under the control of the gun lobby. We must convince our legislature that the will of the people is for sensible gun control unless we prefer to remain World Champions in deaths by firearm.

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What happened to Damar Hamlin?

The media have been focused on the tragic collapse of Damar Hamlin, a professional football player, during a televised game last Monday. Hopefully it will bring more attention to this huge problem: some 350,000 sudden deaths occur annually in the United States, though it is rare for it to happen in a fit athlete.

Some terminology:

This was not a “heart attack,” the lay term for what health professionals call an acute myocardial infarction. An acute MI typically happens to an older person who has (sometimes unknown!) narrowing of the coronary arteries and is generally felt as chest tightness rather than sudden collapse, though this can occur. It would be very rare for a fit young athlete to have coronary disease. While possible, this is unlikely to have happened to Damar.

Nor was it “heart failure,” a condition in which the heart, because of weakened muscle, cannot adequately pump blood and which usually comes on very gradually and whose cardinal symptoms are tiredness and shortness of breath due to fluid backing up in the lungs.

This was a sudden cardiac arrest, in which the coordinated electrical activity that regulates the heart becomes totally uncoordinated. The ventricles, the main pumping chambers of the heart, no longer contract rhythmically. Instead, they quiver in a totally uncoordinated manner, and there is NO effective pumping of blood. This is called VF: ventricular fibrillation. The first organ to feel the lack of blood is the brain, and hence the sudden collapse.

While the commonest cause of this in the general population is coronary disease, in young people there are commoner causes. Bostonians with a long memory will recall the tragic death of Reggie Lewis, star player with the Boston Celtics, who collapsed and died during a practice in 1993.

One possible cause of VF in a healthy person is a blow to the chest which happens to occur at just the wrong time in the heart’s electrical cycle. This is called Commotio Cordis. It tends to be more common in younger males, possibly because their chests are less muscular and a blow is more easily transmitted to the heart. It has been seen in lacrosse or hockey players getting a stick in the chest and baseball players struck in the chest by a ball. This could have caused Damar's collapse.

Another cause is a cardiomyopathy, an abnormality, often congenital, of the heart muscle. If this is very localized, the athlete may be able to perform at a high level but still be prone to VF.

A specific form of cardiomyopathy, that may have been the cause of Reggie Lewis’ sudden death, is hypertrophic cardiomyopathy: the heart is too thick and during exertion there may be severe obstruction of blood flow out of the left ventricle.

The good news is that Damar appears to have been successfully resuscitated and with luck will come out of this tragedy with minimal damage. If so, he will owe his life to the prompt recognition of what had happened, prompt administration of CPR and prompt use of an AED: automatic external defibrillator. This last is a device that allows the general public to give a life-saving electric shock to stop VF without having to wait for medical personnel to arrive on the scene.

Time is critical: the brain suffers irreversible damage if resuscitation is delayed, even if heart function can be restored.

Learn CPR. If you have any influence, see that any place where groups gather has an AED and personnel trained in its use.

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