I had the chance to attend the annual USA Triathlon Race Director’s Symposium this weekend in Colorado Springs.
Along with Stuart Weiss, MD (medical director of the ING NY Marathon. NY City Triathlon, and upcoming Ironman New York triathlon), Richard Miller, MD (a trauma surgeon at Vanderbilt University), Bob Burnett (a New England race director), and Robert Vigorito (a mid-Atlantic race director), I’m serving on a Medical Review Panel convened by USAT to review the experience with race-related fatalities over the past decade and to offer recommendations about improving race safety going forward.
We’ve had a chance to review preliminary information about race-related fatalities from 2003-2011 and I was asked to present some information to about 80 race directors from across the country who were attending the Symposium.
Some Preliminary Information about Triathlon Fatalities
A snapshot of event-related fatalities at USAT-sanctioned events:
-44 athlete fatalities, including 5 traumatic deaths and 39 non-traumatic deaths
-All 5 traumatic deaths occured with bicycle crashes
-Most (and, conceivably all) of the non-traumatic deaths were due to sudden cardiac death (SCD)
-The majority of the non-traumatic deaths occurred in the swim leg of a race, but there were also deaths in the bicycle and running legs….and 2 deaths that occurred after athletes had completed a race and left the race venue
-Deaths occurred in athletes in nearly every age group
-Deaths occurred in races of every distance from short sprint to Ironman distance
Some Information about Sudden Cardiac Death (SCD)
I shared some general information about SCD, describing reports from 2011 on NCAA athletes and on the French general population:
-In NCAA athletes, the incidence of SCD is 1 per 43,770 athletes per year
-Basketball and swimming appear to have the highest risk
-In the French general population, the risk of SCD is 4.6 cases per 1,000,000 population per year
-Deaths were noted in nearly every conceivable sporting activity
-Deaths were noted in individuals from 11 years old to 70+ years old
-Extrapolated to the U.S. population, there should be 4000+ fatalities in the U.S. due to SCD each year
Feedback from the Attendees
I had a chance to hear from the race director attendees about many relevant experiences. Indeed, several of the race directors who were present had firsthand knowledge about some of the fatalities.
Race directors from Utah were able to share with the audience their approach to dealing with the aftermath of such a fatality–from sharing information at the race venue, to working with family members of the victim, to working with the medical and EMS crews who attended to the victim.
There were many suggestions about how we might work to reduce the number of fatalities:
-Easier access to AED’s, including deploying an AED on a boat so that CPR and defibrillation might occur earlier in the event of a swim leg event
-Reducing anxiety among swimmers before the race. Attendees noted that the NYC Triathlon already employs psychologists to conduct pre-race briefings where coping strategies are discussed
-Wearing inflatable devices during a swim which could be deployed if/when a swimmer experienced difficulties
-Designing swim courses to limit the distance from shore
-Having pre-established action plans for the specific possibility of SCD during the swim
One particularly heart-warming story came from a young race director who shared his personal story of having SCD at the swimming pool in 2010, receiving 14 minutes of CPR, and being resuscitated successfully. He now has an internal defibrillator and is working through the issues of how active he can continue to be. He’s continuing his passion for triathlon by serving now as a race director.
A Visit to USAT’s Offices
On the last evening of the Symposium, we visited the offices of USAT for supper and some fellowship. I was totally fascinated by the many photographs and memorabilia on the walls of the office. The highlights were photographs of the Olympic triathlon teams from the 2000, 2004, and 2008 Olympic Games. Really inspiring.
Our Review Panel’s work will continue in the coming weeks as we work to understand more about the athletes who died and about the circumstances surrounding their deaths. I’m optimistic that when we’re finished with our review, we’ll be able to offer some useful advice to USAT and some information to the endurance sport community at large. I’ll keep you posted.
I’d be happy to receive comments and suggestions from the readers here about how we might improve race safety.
In news reports yesterday, I read about the sad news of a triathlete who died during the swim portion of the Ironman Louisville triathlon over the weekend. This death comes just a month or so after the highly publicized deaths of 2 triathletes during the New York City Triathlon. It’s been a while since I’ve written about the issue of sudden cardiac death during triathlons, so I thought I’d share some thoughts.
There has still been little reporting about the tragic event at the Louisville race, but I’ve learned that a 46 year old man was pulled from the water a little more than 300 yards from the start of the triathlon and brought back to the start area to receive further care. Authorities said that he had suffered cardiac death (SCD), was taken to the Louisville’s University Hospital, and was pronounced dead there. I’ve read that an autopsy was performed, but the findings have not been released.
At last month’s New York City Triathon, 2 athletes suffered SCD. One athlete, a 64 year old man died on the day of the event and a 40 year old woman was apparently resuscitated but died a short time later. These deaths attracted a lot of attention in the popular press and I had the opportunity to share some of my thoughts in an article entitled “Why is the Swim the Most Deadly Leg of the Triathlon?” that appeared in the Wall Street Journal. The swim portion of that triathlon was particularly rough and many athletes had to be rescued. Some observers raised questions about conducting the race in those conditions and about the quantity and availability of on-water support to rescue swimmers who weren’t capable enough to complete the swim. I must say, though, that the event organizers are very experienced with directing large triathlons and there appeared to be a robust water safety plan….at least from afar. I was also contacted by The Weather Channel which wanted information and an opinion about how the weather–including water temperature and current–might have played a role in the athletes’ deaths. Again, I suspect this wasn’t a big a factor.
The unfortunate truth is that a small number of athletes will suffer SCD during training or competition….and this is true regardless of the sport. I’ve written previously in a column at Endurance Corner about a recent study by Dr. Kevin Harris of fatalities during triathlon events. In a study of all of the USA Triathlon (USAT) sanctioned events during a 3-year period in the United States, he identified 14 triathletes who died. I recently read in a notice from USAT that nearly 2.3 million individuals completed a triathlon in 2010 in the United States, so you can see how rare an event a race-related fatality really is. Interestingly and importantly, in almost all triathlon fatalities, the victim died during the swim portion of the event and the cause was almost always cardiac-related.
I’ve read through the many discussion threads on this issue at Slowtwitch and other forums and there are obviously many opinions….and many unanswered questions. I think that most of us in the triathlon community could agree that it would be great to prevent some or all of these fatalities, if it were possible. But how?
As I see it, there are only a couple possible ways:
1. Identify victimis of SCD more quickly and provide better and faster medical care so that there might be more survivors.
2. Ensure that, before participating, athletes learn about any heart conditions they might have….and receive necessary treatment and counseling about participating.
USAT Task Force
The week before last I received an email from Rob Urbach, the CEO of USA Triathlon. In that email to USAT Race Directors, he paid special attention to the recent deaths during the New York City Triathlon and indicated that USAT would be convening a taskforce to look at the issue of fatalities during triathlon events. This is a tremendously worthwhile pursuit. I hope that USAT can assemble a group of experts representing the triathlon, medical, and other relevant communities and make a careful assessment of the information that is available about these events. I think this group should:
1. Review the fatalities to look not only for causes of death but also pre-existing medical conditions that might predispose the athlete to sudden cardiac death.
2. Make a careful review of the experience in other endurance (or other) sports (both in and out-of-competition), to place the triathlon statistics into proper perspective.
3. Evaluate the race-day safety resources that are in place to deal with athletes who might suffer sudden cardiac arrest. It is extraordinarily difficult to tend to the victim of SCD in/on the water and we know that CPR and early defibrillation (with just a few minutes) is needed for victims to survive. I’m not aware of any athlete survivors of in-water SCD at a triathlon.
4. Consider what warnings should be issued to participants in terms of the risk of competing and what role that organizers should play (if any) in ensuring the physical ability and medical health of the participants.
As we await the work of the task force, I’d make the following suggestions:
1. For race directors and event organizers. Carefully and critically evaluate your safety plan as it relates to victims of SCD, particularly during the swim. Consider the communication system(s) that are available to water safety personnel and the plans for early CPR and defibrillation should they be needed.
2. For athletes. Realize that there is some small risk of SCD during a race. You should consult with your physician about your particular risk and what, if anything, can be done to reduce that risk. Most athletes would be well served by visiting with a physician for a careful medical history and physical examination that is focused on heart-related problems. Make certain that your overall and heart health are in order before training and competing.
3. For doctors. Become knowledgable about the heart problems that face athletes and be ready to offer sound advice to your athlete patients.
4. For the press. Always give some context for reports on sports-related deaths. Remind your audiences that these events are rare and that exercise provides many proven benefits in spite of any small risk of race-related SCD.
In a scientific article published online earlier this week by Circulation, Eloi Marijon and colleagues at the Paris Cardiovascular Center reported on “Sports-Related Sudden Death in the General Population.”
In recent years there has been a focus on sudden cardiac death (SCD) that occurs in young athletes who are participants in organized and/or competitive sports. There has been much less attention paid to SCD that occurs in athletes (of all ages) who are not part of organized or competitive sports–those who are undertaking so-called recreational sporting activities. The investigators have studied the issue of SCD in this second, much larger group of athletes.
This large, observational study examined the experience in France between 2005 and 2010. The experience included 169,742,000 age specific person-years of follow-up. The investigators considered 2 separate groups:
1. Young athletes, ages 10-35, who were competitive athletes, and
2. Athletes, ages 10-75, who were participants in recreational sporting activities (cycling, jogging, soccer, hiking, swimming, basketball, and others).
Overall, the incidence of SCD was 4.6 per million population per year (860 events total). While a small number of SCD events (50) were observed in the first group, approximately 94% of the SCD events occurred in the group of recreational athletes. If the same statistics were applied to the United States population, we might expect upwards of 4250 cases of SCD among recreational athletes each year.
In the group of recreational athletes with SCD, only 11.7% had a known history of cardiovascular disease or had more than 1 classic risk factor for coronary heart disease. The majority of victims in this group were regular exercisers.
The exact cause of death among the victims was determined for only a minority (24.7%) of the group. If a cause of death was identified, it was cardiac-related in 98%.
The vast majority (93%) of SCD events were witnessed, but bystander CPR was provided in only one third of cases. Survival among the athletes with SCD was very much dependent upon prompt CPR and defibrillation.
The frequency of SCD among recreational athletes is probably much higher than previously thought. This issue deserves and probably will receive additional investigation. The information provided by this report should prompt or renew discussion about the availability of CPR and defibrillation (AED’s) at venues where recreational athletes participate in their sports.