Realm of the Mad God, often shortened to ROTMG or RotMG, is a co-op bullet-hell MMO first released in 2011 by Wild Shadow Studios. Because death in the game is permanent, its low health alerts became deeply familiar to players, triggering real stress during boss fights and crowded dungeons. Clips of near-death escapes helped the sounds spread to YouTube, Twitch and gaming edits, where the low health sound is now used as shorthand for any character barely surviving.