Race safety

More on Triathlon Fatalities–A Scientific Report

September 18, 2017 By Larry Creswell, MD 4 Comments

Readers here at the blog will know that I’ve had a long-standing interest in triathlon fatalities. My interest was originally sparked by media reports and the paradox that seemingly healthy and fit triathletes might die on race day.

I was involved with an internal review of this problem at USA Triathlon (USAT), the governing body for the sport of triathlon in the United States. In 2011, that task force issued a formal report and set of recommendations for athletes, event organizers, and USAT itself. Those written recommendations are still valuable today as we work to reduce the number of triathlon race-related fatalities.

In this week’s edition of Annals of Internal Medicine, I joined with Drs. Kevin Harris and Barry Maron from the Minneapolis Heart Institute in reporting on “Death and Cardiac Arrest in U.S. Triathlon Participants, 1985-2016: A Case Series.” In this scientific report, we’ve gathered information about 122 athletes who died and another 13 athletes who suffered cardiac arrest but survived during triathlon races in the United States over the past 3 decades. This is, by far, the most comprehensive scientific report on this subject.

Special thanks go to the leadership at USAT which recognized the importance of this issue, has been proactive in working to reduce the number of race-related fatalities, and was extraordinarily helpful to our investigative team as we assembled the information for our new report.

The Important Observations

Victims were 47 +/- 12 years old
85% were men
Almost 40% were first-time triathlon participants
There were no elite or professional athletes among the victims
The overall rate for fatalities or cardiac arrest was 1.74 per 100,000 participants (2.40 for men, 0.79 for women). For comparison, the rates of cardiac arrest (including fatalities) are approximately 1.0 per 100,000 participants in marathons and 0.3 per 100,000 participants in half marathons.
The fatality risk in triathlon increases exponentially with age; the fatality rate was 18.6 per 100,000 participants among men 60+ years old
Fatality rates were similar for short, intermediate, and long-distance races
The majority of deaths (74%) occurred during the swim segment; smaller numbers of deaths occurred during the bike or run segments or after finishing the race
Among 22 fatalities occurring during the bike segment, 15 were due to traumatic injuries
At autopsy, clinically relevant (but presumably previously unrecognized) heart/vascular disease was found in many victims

A Recipe for Doing Better

We should focus on two strategies for reducing the number of fatalities: 1) we should work to prevent incidents of race-related cardiac arrest and 2) we should work to improve the survival rate for any such victims of cardiac arrest. Athletes, physicians, event organizers, safety personnel, and sport governing bodies can all play an important role.

Athletes should:

Make certain that their participation in a particular race is in keeping with their health, both chronic and acute, as well as their ability and preparation.
Consider their heart health before participating. This may be particularly true for first-time participants and for men who have reached middle age. For older men, testing for “hidden” coronary artery disease (CAD) or other forms of cardiovascular disease may be appropriate.
Assess their health on race day and consider not racing if they are “sick.” Symptoms, particularly systemic symptoms like fever, are related to DNF rates in other sports settings.
Be prepared for the rigors of a triathlon swim. It is important to be a capable swimmer and to have practiced open water swimming in advance of the race.
Think to STOP at the first sign of medical troubles (unexplained shortness of breath, chest pain/discomfort, or light-headedness), particularly during the swim segment.

Physicians should:

Be aware of the risks of participating in triathlon and be in a position to counsel their athlete patients about those risks in the context of the patient’s specific health situation.
Consider the potential value of cardiac screening, particularly for occult CAD in men who have reached middle age. Evidence-based screening protocols are not yet available, so an approach will need to be individualized. In most cases, an evaluation of the traditional risk factors for CAD would be appropriate and in some cases, additional testing such as calcium-scoring cardiac CT or stress testing may be appropriate. Athletes who are just beginning an exercise program should receive special attention in this regard.

Event organizers should:

Develop a robust safety plan, particularly for the swim segment, that enables prompt (near instantaneous) identification of a lifeless victim, and then rescue of that individual to a location where CPR, defibrillation, and advanced life support can be provided.
Have a communication system for all individuals involved in race-day safety.
Rehearse the safety response to a lifeless victim, especially for the swim segment.

Race-day safety officials should:

Be trained in CPR and use of the AED.
Be familiar, through rehearsal, with the communication and safety plans.

Sports governing bodies should:

Provide education for athletes, event organizers, medical directors, and volunteer safety officials about life-threatening race-day emergencies.
Develop rules and sanctioning requirements that promote athlete safety.

Reference:

Harris KM, Creswell LL, Haas TS, Thomas T, Tung M, Isaacson E, Garberich RF, Maron BJ. Death and cardiac arrest in U.S. triathlon participants. Annals of Internal Medicine 2017 (in press).

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Should You Race When You’re Sick?

July 23, 2017 By Larry Creswell, MD Leave a Comment

We’ve had a fair amount of discussion here at the blog about long-term health, chronic heart conditions, and how exercise may or not be safe. We haven’t talked much, though, about acute general medical conditions, such as simply being “sick.”

Should you race when you’re sick? And, if you do….what might the consequences be?

I had a recent conversation with Chad Asplund, MD, the medical director for one of the Ironman 70.3 races, and Jon Drezner, MD, team physician for the Seattle Seahawks and an editor for the British Journal of Sports Medicine. We were talking about making a list of the concrete steps that triathletes could take to avoid serious medical problems on race day. Dr. Drezner drew my attention to a scientific report from last year that addressed this issue in long-distance running.

Let’s take a look at the study.

The Study

The team of investigators, from Cape Town, South Africa, is involved in the race-related medical care for a collection of on- and off-road running events ranging from “fun runs” to the 56-km Two Oceans Marathon, involving more than 25,000 runners each year. Over the past several years, this group has focused on studying this athlete population with an eye toward identifying, introducing, and testing interventions that might decrease the risk of race-day medical complications in participating runners. Collectively, their work has become known as the SAFER (Strategies to reduce Adverse medical events for the ExerciseR) studies. I’ve previously written here at the blog about the SAFER I study that looked at the “medical toll” of running races.

In the SAFER IV study, the investigators studied the impact of pre-race acute medical illness and do not start (DNS) and do not finish (DNF) rates for runners who competed one year in the 10-km or 22-km trail runs or the 21.1-km or 56-km Two Oceans events (1).

In the 3-5 days before each race, participants were offered the opportunity to complete an online questionnaire about any acute medical symptoms or illnesses that were present pre-race. The questionnaire included both systemic symptoms (headache, general muscle pains, cough, general joint pains, fever) and non-systemic symptoms (sore throat, runny nose, general tiredness, blocked nose, diarrhea, sore ears, abdominal pain, nausea, wheezing, bladder infection, skin rash, vomiting).

Among the participants, 7,031 runners completed the questionnaire. Any runners who reported symptoms received by email some educational material that suggested they not return to running until all symptoms were gone and they felt well again.

The Findings

A total of 19% of respondents reported at least one symptom during the pre-race period; this included 7.5% who reported systemic symptoms. The remaining 81% reported no symptoms (the control group).

In the control group, the DNS rate was 6.6%. In the symptomatic group, the DNS rate was 11.0%. Interestingly, despite the availability of the educational information for the symptomatic group (that recommended not exercising until runners felt well), 89% of those athletes started the race. For those runners who reported any systemic symptoms, the DNS rate was 15.1%.

In the control group, the DNF rate was 1.3%. In the symptomatic group who started the race, the DNF rate was 2.1% (1.6 times greater than control). For those runners who reported any systemic symptoms and who started the race, the DNF rate was 2.4% (1.9 times greater than control).

The investigators concluded: 1) symptoms of acute illness were relatively common during the pre-race period; 2) despite such symptoms and despite educational materials that discouraged participation, most athletes chose to start the race; and 3) pre-race symptoms of acute illness significantly increased the chances for a DNF.

My Take on The Study

This study is intriguing because it is the only prospective study to address the impact of pre-race acute illness on race-related performance, in any sport. First, a couple notes about the study’s limitations are in order.

First, the response rate for the pre-race survey was rather low (26.6%). The authors indicate that the respondents did not differ substantially from non-respondents in terms of demographic data, but whenever a survey response rate is low, there is a possibility of unwanted bias.

Second, no information is available on the reasons for any athlete’s DNF. Clearly, it would be more informative if pre-race symptoms could be correlated with specific race-day medical problems that might cause the athlete to DNF.

In spite of those limitations, the investigators make some important observations in their running population, but these observations can probably be generalized to other athlete populations:

Nearly 1 in 5 athletes were “sick” in the days leading up to their race. This is a lot of participants.
The vast majority of “sick” athletes probably ignored warnings about participating until they were well (although certainly some may have felt better by race day).
Pre-race “sickness” with systemic symptoms was associated with a nearly doubled risk of DNF. That’s a big effect on performance, even if finer distinctions such as finishing times could not be discerned.

Thinking about the implications, athletes and their physicians should be aware of the potential negative consequences of racing when “sick.” Race organizers should consider distributing educational information about these negative consequences, while recognizing that athletes may not accept unwanted advice not to participate. Many factors (investment in training, scheduled time off from work, costs associated with the race/travel) may be barriers in athletes’ acceptance of such advice. Lastly, additional studies would be helpful if they examined: 1) race-day medical conditions and their relationship with pre-race symptoms; and 2) other measures of performance such as actual versus expected finishing times.

Reference:

Van Tonder A, Schwellnus M, Swanevelder S, Jordaan E, Derman W, Janse van Rensburg DC. A prospective cohort study of 7031 distance runners shows that 1 in 13 report systemic symptoms of acute illness in the 8-12 day period before a race, increasing their risk of not finishing the race 1.9 times for those runners who started the race: SAFER study IV. Br J Sports Med 2016; 50:939-945.

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The Medical Toll at Endurance Events

An Open Water Swim Safety Idea

February 26, 2016 By Larry Creswell, MD 1 Comment

As I mentioned in my last blog post, I recently visited in Tokyo with the Japan Triathlon Union about the issue of athlete safety. I had the chance to speak (albeit with translation!) with the race directors from many of Japan’s major triathlon races.

Dr. Masakazu Kawai, from the Yamagata prefecture, had a novel idea about swim safety to share with the group.

But first, to set the stage….

We know that being able to rescue a swimmer in distress in one of the most important aspects of an effective safety plan for a triathlon or stand-alone open water swim. Fortunately, in most cases, the on-water lifesaving team is able to spot swimmers in distress who might be struggling to swim, or wave, or even simply yell that they need help.

For the lifeless swimmer–the victim of drowning, near drowning, or cardiac arrest–identification of the victim can be much more challenging. And yet identification of the victim, prompt rescue from the water, and provision of CPR and use of the AED, if needed, is the chain of action that must be accomplished in just a very few minutes in order to avoid a fatality. This chain all begins with identifying the victim.

In a crowd of swimmers, oftentimes all wearing black wetsuits, it can be hard to spot the single athlete who has gone lifeless and who is floating, but no longer swimming. From afar, it can be difficult to tell whose arms are whose and it can be difficult to tell if a head is rotating to take a breath.

This is where Dr. Kawai’s idea might be helpful. He suggests the use of a small, inflated, brightly-colored balloon that would be attached to each swimmer’s swim cap. As the athlete is swimming, the balloon would bob left and right, with each turn of the head. If an athlete goes lifeless, the balloon would simply sit still on the top of the water. In a group of swimmers, then, there would be a very visible clue to a single lifeless swimmer–the single balloon that was no longer bobbing. This might be visible even from a considerable distance and allow early, perhaps immediate, recognition of the lifeless swimmer.

Watch a short video clip that shows the idea and let me know what you think. I’ll pass along any feedback to Dr. Kawai. He’s also looking for event organizers to trial his idea. We need simple, creative ideas like this.

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USAT Medical Multisport Conference

May 21, 2015 By Larry Creswell, MD 2 Comments

I had the chance to be a speaker at the November, 2014 USA Triathlon (USAT) Medical Multisport Conference that was held at the Olympic Training Center in Colorado Springs. The weekend brought 2 days of talks that focused on aspects of sports medicine that were particularly relevant to triathlon and multisport.

Travis Tygart, CEO of the United States Anti-Doping Agency (USADA) was the keynote speaker. We heard about event and safety planning from a very experienced group of USAT-affiliated physicians, including W. Douglas Hiller, MD, Andrew Hunt, MD, and John M. Martinez, MD. I gave talks on some of my favorite topics: “Triathlon Fatalities,” “Endurance Sport: Is it Heart Healthy?,” and “Cardiovascular Considerations in the Aging Athlete.” We had lunch with Kathy Matejka, the USAT Event Services Director and dinner with Rob Urbach, CEO of USAT.

I met some terrific folks and I learned a lot.

It was great to visit the Olympic Training Center. I particularly enjoyed the museum area and a workout at the pool. The snow and cold weather got the best of a planned group run, though.

This year’s Conference is planned for November 5-7, 2015, again at the Olympic Training Center in Colorado Springs. This year’s keynote speaker will be Robert Laird, MD, the original and long-time medical director for the Ironman World Championship race in Kona, Hawaii. This would be a worthwhile meeting for anybody who’s involved with medical care of multisport athletes, including nurses, physicians, and allied health professionals. Information about the meeting schedule, speakers, and registration can be found at the USAT website.

I hope that you’re able to join us in November!

Mixed Emotions About The Medical Tent

September 17, 2014 By Larry Creswell, MD 4 Comments

I’m fascinated by the medical tent at endurance sporting events. Maybe that’s not surprising. After all, I’m a doctor and an athlete.

I have mixed emotions about the medical tent, though. Maybe you do, too. Let me explain….

Dr. Laird and the Kona Medical Tent

I got to thinking about the medical tent this past month when I listened to a talk given by Dr. Robert Laird, the long-time (now retired) medical director for the Ironman World Championship race in Kona. He gave a talk at a sports medicine symposium held in conjunction with this summer’s Challenge Atlantic City events. He told the ~23-year history of medical support for the Ironman race, beginning with its first year in Kona in 1981. That year, Dr. Laird stood on the pier watching the swimmers, dressed in running gear, stethoscope around his neck, cap on his head….and he alone was the extent of the medical support.

Of course, today it’s much different. On race day, there is a 50- to 60-bed field hospital set up in a tented area across from the Kailua Pier. It’s arranged in pods of 6 patient beds and staffed with many physicians, nurses, physical therapists, and non-medical volunteers as well. On race day, it’s the 3rd largest “hospital” on the Big Island of Hawaii. And on race day, up to several hundred athletes among the nearly 2,000 participants in the race receive medical care there.

The medical support team also has a fleet of makeshift “ambulances”–rented white vans with a temporary red cross affixed to the side. Without these vehicles, the need to respond to athletes on the 112-mile bike course or 26.2-mile run course would overwhelm the resources of the local EMS system.

If you’re an athlete with medical needs on race day, the setup is awesome. In truth, the Ironman event as we know it today would be impossible to stage without this elaborate medical support.

My Own Medical Tent Memories

Thankfully, I’ve avoided the medical tent as a patient. I did take a break at a medical aid station along the run course at the 2012 Ironman New Zealand race when I was feeling poorly. But after a cool refreshment, some much needed shade, and a short break, I was able to continue along my way.

I’ve waited near the doors of the medical tent on a couple occasions, though, while my athlete friends were receiving treatment. I remember my buddy, George, losing 12 pounds during the Ironman New Zealand race in 2007 and needing rehydration. I also recall my friend, John Pendergrast, an ophthalmologist, needing treatment for a couple hours after finishing the Ironman South Africa race. Our small group of traveling partners waited anxiously to be sure that John was okay.

I volunteered once in a major medical tent–for the Ironman Florida race. I worked the 6 pm to midnight shift. My lasting memory will be of the athletes who arrived at the finish line and then collapsed. On a day with high temperatures in the gentle 70’s I was surprised at how many athletes arrived at the medical tent at the finish line severely hypothermic and dehydrated. It seemed that the athletes who were worst off were those who arrived after finishing the race in 10-11 hours or so. Perhaps the later arrivals had gone too slowly to get “messed up.” We treated a bunch of athletes that night.

I’ve enjoyed reading the accounts of others who’ve worked in the triathlon medical tent. Check out the report by professional triathlete and physician, Tamsin Lewis.

Marathon Medical Tents

Of course, the medical tent today isn’t confined to triathlon. There is elaborate medical safety planning for the major running races, too. There is often a medical tent at the finish line of the big city marathons and these are often staffed, at least in part, by volunteers.

I recently attended a lunchtime lecture given by one of my cardiology colleagues who had volunteered at the medical tent for the Boston Marathon. There’s a sports medicine symposium before the race and the attendees are offered the opportunity to volunteer in the medical tent. This gives physicians a chance to put into practice what they’ve just learned. Listening to his tale, I get the impression that virtually any medical problem can manifest during the marathon, but that dehydration and heat-related illnesses are the common medical ailments. He shared (and I’ve heard from others as well) that ice baths for rapid cooling of victims with severe heat-related illness probably make the difference for survival–that the EMS system and local hospital emergency rooms might not have the available resources to get athlete patients cooled so quickly. That’s an eye-opener.

Malpractice Insurance Issues

I’ve often wondered–and even worried–about the issue of malpractice insurance coverage for physician volunteers at medical tents. It’s one thing if you’re an emergency physician or sports medicine physician. But it’s another situation entirely if you’re volunteering in a capacity outside your specialty–and perhaps outside the state where you’re licensed. The issue would seem to be relevant not only to physicians but also to nurses and other licensed healthcare professionals as well.

It would be interesting to know if there are instances of malpractice lawsuits brought by athlete-patients against medical tent volunteers. I’m told by the folks at USA Triathlon (USAT) that they’re not (yet) aware of any instances.

In order to encourage volunteer participation by medical professionals at triathlon medical tents, USAT has organized a malpractice insurance coverage opportunity. This opportunity hasn’t received much publicity. For a very modest premium, any licensed medical professional can obtain insurance coverage in situations where their own policies wouldn’t be applicable. I bet this would help put some potential volunteers’ minds at ease and encourage their involvement.

The Mixed Emotions

So, back to the mixed emotions. No doubt, the medical tents at triathlon and major running events provide a useful and needed service. In some cases, it would be impossible to hold events without an organized medical safety net that includes an on-site medical tent. And no doubt, countless athletes have benefitted from care they’ve received by volunteers at these medical tents. So, in the sense of providing a safety net for participants, the medical tent is great.

But on the other hand, I have to wonder if the very existence of the medical tent and ready availability of volunteer medical care doesn’t encourage unsafe behavior on the part of athletes or event organizers. I also wonder how outsiders view this whole enterprise. Surely, if intravenous hydration is required by large numbers of participants just to complete an event, there must be something wrong–either in the venue, the weather conditions, or the preparation of the athletes. Yet I hear many athletes talk casually about how they’ll “just get an IV” after the race.

At any rate, this is all food for thought. I’m intrigued by the medical tent. I hope it’s there when I need it, staffed by capable healthcare professionals. I’ll probably volunteer again, too. But I’ll also have some nagging worries.