Drs. Webber, Nye, Harmon, and O'Connor:
The vital point is that, by and large, exertional rhabdomyolysis (ER) from exertional sickling (ES) tied to sickle cell trait (SCT) is the only ER that can directly kill warfighters or athletes. The ischemic ER of major ES too often is “explosive,” and so can evoke a “metabolic storm” (including dire lactic acidosis and hyperkalemia) that can stop even a normal or athletic heart.
You tried to answer a question you had after your second CHAMP summit on SCT (October 2019): Is ER experienced differently according to SCT status? You reviewed charts, via an existing electronic medical database, on USAF cases of ER over 10 years (2009–2018), keying on context, triggers, progression, and severity. You concluded: “Although SCT is a risk factor for developing ER, it does not appear to influence its progression or severity.” You got the wrong answer.
You found no ER deaths in the 10 years of your study. But there were at least 8 USAF deaths from the ER of ES during that period, and 3 more within 8 months of the end of your study. You say no airman with ER who went to an intensive care unit (ICU) had SCT, but at least one did. I have spoken in depth with that lone ES survivor. He spent 2 wk in an ICU. He was “out of it”; when he awoke on day 13, he thought it had been 2 d. He got hemodialysis and fasciotomies for grave ER. On leaving the ICU, he was too weak to walk alone. He lost 40 lbs of muscle, spent >1 month in the hospital, and took months to regain full leg function. I also have files on the 11 dead airmen with explosive ER from ES.
All 12 collapsed near or soon after the end of their USAF 1.5-mile timed fitness run. Your data reflect this: 5 (45%) of your 11 SCT-positive developed their ER from the Air Force Fitness Assessment (read “run”) versus 34 (18%) of your 174 SCT-negative plus 15 SCT-unknown (P < 0.05 by χ2). My files suggest command errors that would seem easy to avoid. I will not go over them here. But I suggest this: Give those with SCT just 2 to 3 min more to complete the USAF 1.5-mile “fitness” run, and odds are none will collapse or die from ES.
Bottom line: I agree you were transparent as to your limitations. Also, I never thought (or said) your military misdirection errors were willful. But your conclusion is wrong. Deadly wrong.
E. Randy Eichner, MD, FACSM
The author declares no conflict of interest and does not have any financial disclosures.