An Open Water Swim Safety Idea





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.









Related Posts:

  1. Some Great New Videos from WTC SwimSmart Initiative
  2. Swim Safe in 2014
  3. Triathlon Safety Initiatives

USAT Medical Multisport Conference








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





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.

Some Great New Videos from WTC SwimSmart Initiative

Here’s a quick update from the World Triathlon Corporation (WTC) SwimSmart initiative.  They’ve put together a YouTube playlist called “SwimSmart Saturdays,” a 9-part series of short (~1-2 minute) video clips that illustrate their 9-point checklist for race day swim safety:

  1. Prepare Early
  2. Work Your Way Up
  3. Be in the Know
  4. Safety First
  5. Tried and True Gear
  6. Warm Up Right
  7. Assess the Situation
  8. Start Easy, Relax and Breathe
  9. Be Alert and Ask for Help

This is all great advice for triathletes looking to have a safe day at the race.

Related Posts:

1.  Swim safe in 2014

2.  USAT and race safety

3.  Triathlon fatalities:  2013 in review

Medical Toll at Obstacle Race




A couple weeks ago I wrote about the medical toll at long-distance running events.  There was also a recent report on the medical toll at an obstacle course race that caught my eye.  On the face of it, the findings were surprising!

At the outset, let me issue a disclaimer.  I haven’t participated–or even spectated–at one of these obstacle course races, so I may not have the best perspective.  I’m talking, though, about races like the Tough Mudder, Warrior Dash, and Spartan Race, among others.  They’ve become very, very popular very, very quickly.  We’re talking 100’s of thousands of participants per year in the U.S.  One day, I’ll give it a try.  I’ll need to be brave!


The Study

A group of investigators headed by Marna Greenberg, DO, MPH, in the Department of Emergency Medicine at Lehigh Valley Hospital reported on a collection of patients who required hospital care stemming from their participation in an obstacle course race.  The event was the Tough Mudder Philadelphia race, held over the weekend of June 1, 2013.  As you may know, the Tough Mudder races are characterized by a 10- to 12-mile course with a series of 20-25 obstacles spread over the course.  By report, approximately 22,000 individuals participated in this particular race.

The investigators were the emergency room physicians at the hospital that was designated to care for participants who required hospital care for medical conditions or injuries that developed during the race.  In a report in the Annals of Emergency Medicine entitled “Unique Obstacle Race Injuries at an Extreme Sports Event:  A Case Series”, they share their first-hand experience which they characterized as surprising.


The Results

The report provides fair detail about 5 patients with “significant” injuries or diagnoses and compiles a list with pertinent findings in 43 total athletes who received care at the hospital. The 5 athletes with “significant” problems included:

  • 18 year old with myocarditis (inflammation of the heart muscle) caused by electrical shock during the event.  Required admission for 2 days.  Self-limited.
  • 28 year old with depressed level of consciousness and diagnoses of accelerated hypertension (high blood pressure) and pericarditis (inflammation of the sac that holds the heart).  Required admission for 2 days.  Self-limited.
  • 31 year old right-sided weakness who was found to have a stroke, seizure, and dehydration.  Required admission to the intensive care unit (ICU).  Was discharged to a rehab facility and at the time of writing, had persistent weakness due to the stroke.
  • 41 year old who experienced syncope (blacked out) after being shocked at an obstacle.  He fell, causing lacerations to the face.  He was discharged from the emergency room against medical advice to be hospitalized.
  • 25 year old woman with near syncope (nearly blacking out) because of electrical shock.  Required hospitalization for evaluation and was treated for dehydration and rhabdomyolosis (breakdown of muscle).

The 38 others had diagnoses that included:  heat injury, sunburn, ear barotrauma (pressure injury), shoulder dislocation, patella dislocation, heat exhaustion, vomiting, renal failure, various contusion injuries, rib fracture, dehydration, asthma, seizure, leg fracture, ankle sprain, and elbow sprain, among others.


The Takehome Messages

You never read about the medical toll at running races that are shorter than half marathon distance.  That’s not to say that athletes don’t have injuries or other medical problems manifest during those races.  It’s just that athletes are usually responsible for their own medical care or receive their care from the emergency medical system (EMS), rather than by race-supplied medical volunteers.  So nobody is keeping track of the “toll.”

This report is great peak into the issues with the obstacle races.  Kudos to the authors for sharing their experience.  Obviously, 43 victims among 22,000 participants is a small fraction.  We might reasonably expect, though, that additional athletes with minor injuries or medical conditions did not visit the hospital for care.

Some thoughts….

  • At an obstacle course race, the obstacles present a challenge and risk that is different from just running.  These events are certainly not risk-free.
  • There are typical medical issues like minor injuries, dehydration, and heat injury.  Some injuries and medical problems may be due very specifically to the obstacles themselves.
  • There will also be injuries that may not be expected–either by the athletes or by the nearby healthcare workers.  At this particular event, the myocarditis, pericarditis, stroke/seizure, and syncope diagnoses were examples.  Electrical shock was an unexpected causative factor.
  • Athletes should keep the potential risks in mind when they decide to participate and exercise great care while participating.

Like I said at the top, I’ll probably be a participant at some point.  But I’ll need to be brave!