Dr Larry Creswell
There is a great article about triathlon race safety in the Spring 2014 edition of USAT Magazine. The article shares strategies for athletes, event organizers, and USA Triathlon itself to help ensure everybody’s safety this triathlon season. This is must reading for the triathletes out there!
Download the USAT-Safety-Article.
At my column this month at Endurance Corner, I wrote about age group triathletes and doping. Based on athlete questionnaires, a recent study found that about 15% of age group triathletes at three long course events in 2013 reported some form of doping in the preceeding year. I shared some information about the study and its findings as well as some of the cardiovascular concerns with the common doping agents.
Looking at the Tweets and comments today, some are surprised the rate is so high….and others are surprised it’s so low. I’m not surprised.
With the 2013 triathlon coming to a close here in the United States, I thought I’d provide an update about triathlon fatalities. I’ve been working on a talk for next month’s USA Triathlon (USAT) Race Directors Symposium about this issue and it gave me the opportunity to gather some new data about the 2012 and 2013 seasons. I’ll also reflect on the media coverage of this issue in 2013, point you to some resources that may be helpful for athletes and event directors, and share my thoughts about the challenges and opportunities that remain.
The USAT 2012 Report
It’s been just over a year since USAT released its final report on event-related fatalities from 2003-2011. In addition to providing information about 45 fatalities during that 9-year period, the report concluded with a set of recommendations, in a framework of shared responsibility, for athletes, race directors, and USAT itself. The report is worthwhile reading for everybody in our triathlon community. I still believe that all of the reasonable opportunities for reducing the number of fatalities are included in those recommendations.
Media Attention in 2013
The issue of triathlon fatalities continues to receive attention in the media. Each of the fatalities in 2013 drew the attention of the local media and some garnered attention in the national media as well. The death of Ross Ehlinger at this year’s Escape from Alcatraz Triathlon in March received the most attention, with widespread reporting in the national media. I was at the race that day and shared some of my thoughts in a previous blog post. There was a fair bit of criticism in the media about issues such as particularly difficult water conditions for the swim that day, unusually cold water temperatures, an earlier-than-usual event date, and a large number of swimmers who required rescue or repositioning during the swim portion of the event. We learned months later from autopsy information that Ehlinger had significant, unrecognized coronary artery disease. Early speculation in that regard turned out to be correct.
The issue also received national attention in May in a short report in USAToday entitled Swimming Deaths Trouble Triathlon Officials. That report included a table (essentially from the USAT report) that recognized again the large proportion of fatalities that had occurred during the swim portions of events over the years. The article highlighted the stories of several athletes who died during the 2012 season and offered commentary by USAT CEO, Rob Urbach, and Dr. Rudy Dressendorfer about potential mechanisms and causes.
ESPN took an interest in this issue and worked with USAT to gather information during the early part of the 2013 season. In October, long-time ESPN reporter Bonnie Ford wrote an article enetitled Trouble Beneath the Surface, that examined in some detail the facts surrounding swim-related fatalities in triathlon. The article raised questions not only about athlete preparation for events but also about safety-related preparations by event organizers. As part of its Outside the Lines program, ESPN also released a short video report by T.J. Quinn that paralleled Bonnie Ford’s reporting. I was able to join Ford, Quinn, and cardiologist John Mandrola, MD, as a panelist for that broadcast which is available now as an archived podcast. I wrote about the experience in more detail here at the blog. The discussion was pretty short, but we had a chance to talk about both athlete and event organizer responsibilities for improved safety. I’ll thank ESPN for taking on the issue and drawing our attention to opportunities for improvement in race-related safety.
The public scrutiny this year wasn’t directed only at triathlon, though. The Tough Mudder series of races came under criticism for the general health risks of participation. An article in the NY Daily News was typical of the reporting about seemingly high rates of athlete injuries and emergency room visits. The death of an athlete at an April race at the Walk the Plank obstacle, presumably because of drowning, also received considerable attention in the media. This article in Outside Magazine is typical of the reports that raised concerns about safety planning and inadequate lifeguard resources for the large number of participants.
The 2012 and 2013 Fatalities
The USAT 2012 report detailed the event-related fatalities for 2003-2011. We’ve had 2 seasons since then. The fatalities in 2012 and 2013 occurred against a backdrop of continued strong participation numbers for the sport in the United States.
In 2012, there were 4,310 sanctioned events where there were 565,325 finishers. Fourteen athletes died, a fatality rate of approximately 1 per 40,000 participants. It appears that 2012 had the highest fatality rate in the past decade. Thirteen athletes died during the swim portion and the remaining athlete died during the bike portion of an event. These athletes included 13 men and 1 woman who ranged in age from 34 to 69 years.
In 2013, through November, there were 4,084 sanctioned events where there were a total of 512,972 finishers. Eight race participants died, a fatality rate of approximately 1 per 64,000 participants. Five athletes died during the swim, 2 died during the bike, and 1 died during the run portion of an event. These athletes included 6 men and 2 women who ranged in age from 31 to 70 years.
An additional athlete died in 2013 during an event-sponsored practice swim the day before a sanctioned race which was then cancelled because of the fatality. There has been ample discussion these past couple years about the value of a swim warm-up immediately before a race. No doubt, this can be helpful in many ways. But we must remember that sudden cardiac death can occur at any time–not only during a race. In fact, the vast majority of sports-related sudden cardiac deaths each year occur outside of competition.
From press accounts, we know of 1 survivor of cardiac arrest during the bike portion of the August 4, 2013 edition of the Cleveland Triathlon. Todd Rains, a 44-year-old man, collapsed during the bike portion of the event, received prompt CPR by fellow participants, and was successfully resusciated. The number of such incidents at triathlons remains largely unknown. Given that the survival rate for out-of-hospital cardiac arrest is thought to be <15%, I suspect the number is small.
Updated Overall Statistics
With the addition of the 2012-2013 data to the previously reported 2003-2011 data, we now know there have been 68 event-related fatalities over an 11-year period. That span includes nearly 32,000 events with more than 4 million participants. Narrowing the focus a bit, we might include only the 65 athletes who died at a race, and exclude the 1 spectator death, 1 fatality at a clinic rather than a race, and the 1 death during the practice swim. In terms of race-related incidents, the approximate fatality rate since 2006 is approximately 1 per 65,000 participants.
If we include all 68 athlete fatalities, 49 (72%) occurred during the swim, 11 (16%) during the bike, 4 during the run, 2 after the race, 1 in a spectator, and 1 in a pre-race practice swim.
Coverage in the Triathlon Media
The issue of race safety garnered the attention of the triathlon media in 2013. I’d like to thank the various editors.
In the April, 2013 issue of Triathlete Magazine, Warren Cornwall, a triathlete, wrote an article entitled What Lies Beneath. That article is now available online with a new title, “Are You Fit to Race Triathlons?” Cornwall’s interest in triathlon race safety was spurred by his participation in the 2012 USAT National Championship races in Burlington, Vermont, where Richard Angelo died during the Olympic distance race. Cornwall writes about the potential causes of athlete fatalities and shares his personal story of undergoing a cardiac evaluation. He offers a good sidebar on the pros and cons of various diagnostic tests to determine “Are You Fit to Race?”
In the 2013 edition of New Zealand’s Iconic Adventures magazine, Mark Banham wrote an article entitled, “Heart of the Matter.” He addresses the issue of sports-related sudden cardiac death, starting with the ancient story of Phillipdes and then turning to modern endurance athletes. He offers a set of heart health tips that will be useful for athletes.
The November/December issue of Inside Triathlon featured an article by Torbjorn Sindballe, entitled “From the Heart.” Sindballe, as you may know, retired from the sport of triathlon in 2009 because of problems related to a heart condition known as bicuspid aortic valve (BAV). He was born with an aortic valve with 2, rather than the normal 3, leaflets. With time, individuals with BAV are predisposed to having problems with leakage–or regurgitation–of the valve as well as enlargement of the nearby aorta. Sindballe developed both of these problems. He describes the diagnosis of his condition in 2005 and talks about how this impacted his elite triathlon career. He includes 4 tips for a long and healthy life: 1) react immediately to serious symptoms; 2) get a check-up; 3) chase your dreams, but respect your body; and 4) change triathlon’s overachieving culture. All good advice.
In the December online edition of Triathlete Europe, Drs. Merghani, de Meyer, and Sharma wrote an article, entitled “Cardiac Screening: Heart Health and Triathlon.” Written by a group of authors who are among Europe’s foremost experts in sports cardiology, this article addresses some of the underlying cardiac causes of sports-related sudden cardiac death and talks about the value in cardiac screening for endurance athletes.
Resources for Athletes
A couple new resources for athletes in 2013 deserve mention.
As part of its SwimSmart initiative, World Triathlon Corporation (WTC) produced a short video on swim safety narrated by Paula Newby Fraser. Fraser details a 10-point safety checklist as triathletes prepare for their next triathlon swim. This checklist is applicable to all triathletes–not just those participating in Ironman events. Ten minutes listening to this video might save your life.
USAT has a very active webinar program. Their listing of upcoming as well as archived webinars is available here at the USAT website. Earlier this year I hosted a webinar on Heart Health and Endurance Sport, a 45-minute look at some of the heart issues that are faced by endurance athletes. A portion was devoted to the topic of cardiac screening of athletes. Best of all, it’s free!
I’ll mention that I’m toying with publishing a very short eBook that deals with triathletes, open water swimming, and safety. The book would answer the question: What can I do as an athlete to make my next triathlon swim as safe as possible? I’d like to reach as many triathletes as possible and I’d like to leave readers with a simple, ~10-point plan. Please let me know if you have advice, suggestions, etc.
Resources for Race Directors
Several developments on the race director front in 2013 deserve mention.
USAT issued a new set of Recommendations for Multi-sport Age Group Swim Segments regarding water temperature. I’ve written about this issue in a previous blog post. This is a step forward, bringing USAT into the collection of governing bodies that have thoughtfully considered the issue of water temperature and athlete safety. All of us in the triathlon community will need to become familiar with the new recommendations. Both athletes and event directors should be familiar with the safety issues and possibilities of hypothermia or heat-related illness at the extremes of water temperatures. I understand that USAT will be rolling out infomational pieces as we move into the 2014 race season.
I mentioned at the top of this post that I’m speaking at the upcoming USAT Race Directors Symposium. This year’s event will be held as a virtual, rather than an in-person, symposium. Check out the details at the USAT website.
WTC and Rev3 Triathlon each rolled out water safety initiatives this year. I wrote about the details in a previous blog post at the start of the season. I mentioned the WTC water safety video earlier. Let me also mention a collection of 4 articles on athlete swim safety written by professional triathlete, Malaika Homo, for Rev3. They’re good reading. I know that the WTC and Rev3 initiatives got a lot of attention this year both inside and outside of the triathlon community. I hope that these organizations will report back about their successes and their thoughts about a course forward.
There are several recent and upcoming USAT webinars on the topic of race safety, and that are targeted to event directors: Setting Up Your Medical Team for a Long Course Event–J. Rizzo; Emergency Management Plan Case Study: Preparing for the Unexpected–E. Sarno; Preparing for the Storm: A Look into Crisis Management–B. Davison; and 9-1-1: Preparing for Emergencies at Your Event–J. Flint.
USAT is planning for a first annual conference for medical professionals in May, 2014 at the Olympic Training Center in Colorado Springs. Details should be available soon. The 2-day conference will be targeted at medical professionals with involvement in multi-sport event planning and management. Athlete safety will figure prominently in the program. I’d encourage event organizers to pass this information along to their events’ medical directors and staff.
Lastly, I’ll point out an interesting panel session at the upcoming Triathlon Business International conference next month in Los Angeles. Targeted at race directors, the January 27th panel session on the “Hot Topic” of water safety will include: Bill Burke, race director; Bonnie Ford, ESPN reporter; Dan Ingalls, National Marine Safety Center; Captain Danny Douglas, Venice Beach Lifeguard Operations; and Charlie Patten, Rev3 Triathlon. This should be a lively session!
Challenges and Opportunities
Our challenge remains to reduce the number of athlete fatalities at triathlons. Athletes, event organizers, and USAT all have a role to play. I’ve been encouraged this year by the level of engagement about this issue. As a community, our awareness may never have been greater. But there’s obviously more work to do. Even a single fatality is one too many. So here ‘s what I’d like to see in 2014:
Education and awareness. I hope that the issue of race safety will continue to receive attention by the triathlon media in 2014. I’m convinced that athletes want information that may help them train for and compete in triathlons safely. Let the various editors know that race safety continues to be an important issue. USAT and the other relevant governing bodies can also help with print, video, webinar, or in-person educational activities. Topics related to heart health, cardiac screening, and athlete preparation for open water swimming would appear to be the important topics for athletes. If you have expertise in these areas, volunteer to help USAT in their efforts, volunteer to help your local race director, or offer to speak to your local tri club. I know they’d be happy to hear from you. I also hope that the media outlets will work hard to find and share the good stories–the stories of athletes who had major medical problems at events, but overcame them and are back to training and competing. We don’t hear enough of those stories.
Further investigation. USAT is partnering with Kevin Harris, MD, from the Minneapolis Heart Institute to investigate in further detail the medical histories, initial treatment, and autopsy information for athletes who’ve died at triathlons in the past decade. This is a big undertaking. I’m hopeful that this investigation will shed additional light onto the causes of the athlete deaths and suggest additional steps we might take in the future to make racing more safe. As part of that work, we will be trying to identify survivors of cardiac arrest at races. If you know of such an athlete, please let me know. Often, there is a lot to learn from the so-called near misses. I’m hopeful that much of this work will be completed in 2014 and that I might be able to report back at this time next year with some highlights. There are probably countless areas of worthwhile investigation when it comes to athlete safety and multi-sport events. If you’re an investigator with an idea for a potential study, I’d urge you to be in touch with USAT. Maybe it’s a project on athlete pre-race anxiety. Or, perhaps it’s a project related to swimming-induced pulmonary edema (SIPE). If there’s an interest in improving athlete safety, I bet they’d be receptive.
Safety planning. Event organizers must continue to work on planning the safest possible events. Given the information at hand about athlete fatalities, safety planning for the swim portion of events should obviously receive special attention. It’s critical that safety plans and lifeguarding resources allow for the almost immediate identification of a lifeless swimmer and then rescue so that CPR and early defibrillation can be provided. It seems simple, but it’s logistically complex. My hope for 2014 is that the event director community will work together to develop educational materials and best practices that can be shared widely. USAT could facilitate this exchange.
I remain optimistic that, together, we can make a difference in 2014.
At its November meeting of the Board of Directors, USA Triathlon (USAT) adopted new Recommendations for Multi-Sport Age Group Swim Segments. These new recommendations mark a step forward in terms of race safety. USAT also agreed to collect data during the 2014 season from every event regarding water temperature and athlete rescues, incidents of hypothermia or heat-related illness, and other medical emergencies that occur during the swim portion. These data will help to guide further review of the recommendations by the USAT Swim Collar Task Force and possibly set the stage for further scientific investigation about hypothermia and heat-related illness in the triathlete population specifically.
The graphic below illustrates the new recommendations:
These recommendations are targeted at race directors, local officials, and athletes. They apply to age group events but not to professional races. Satisfactory, or so-called neutral, water temperature ranges for races of various distances are defined as:
The neutral temperature ranges are shown in green in the graphic. When the water temperature falls outside of the neutral range, the recommendations advise that the swim portion should be shortened or cancelled. These temperature ranges are shown in yellow or red in the graphic. Discretion is left to the race director, though, who may consider other safety-related factors such as air temperature, humidity, acclimation, regional adaptation, and wind.
There is no change to the current rules regarding measurement of the water temperature or to the use of wetsuits. From the USAT competitive rules:
Measuring Water Temperature. It is recommended, but not required that the water temperature for a race be finally determined by measurement made within 2 hours of the race start. A water temperature measurement should also be taken prior to any pre-race meetings in order to forecast to the athletes as early as possible the likely water temperature on race day and the likelihood of whether wet suits will be allowed on race day.
Wet suits. Each age group participant shall be permitted to wear a wet suit without penalty in any event sanctioned by USA Triathlon up to and including a water temperature of 78 degrees Fahrenheit. When the water temperature is greater than 78 degrees, but less than 84 degrees Fahrenheit, age group participants may wear a wet suit at their own discretion, provided however that participants who wear a wet suit within this temperature range shall not be eligible for prizes or awards. Age group participants shall not wear wet suits in water temperatures equal to or greater than 84 degrees Fahrenheit.
Open Water Swimming, Hypothermia, and Heat-related Illness
Open water swimming is as old as the ages. Mass participation in open water swimming events is relatively new, though.
In today’s triathlons and open water swimming events, there is tremendous heterogeneity among the participants in terms of age, size, body fat, and swimming ability. All of these factors affect an individual athlete’s ability to withstand prolonged exposure to cold or warm water temperatures. The important concept is maintenance of core body temperature. In ordinary circumstances, the human body core temperature is tightly controlled to reamin near 37 C by processes known as thermoregulation. There is a balance between heat gained from the environment or generated by exercise….and the heat lost to the environment.
The condition of hypothermia is loosely defined as a core body temperature <35 C. With mild hypothermia, there may be an increase in the blood glucose level and increases in both the heart rate and respiratory rate. With a continued fall in core body temperature, shivering begins, muscle movements become labored and then difficult, and mental confusion develops. This progression can be insidious. Athletes should be vigilant. With severe hypothermia, the heart rate and respiratory rates fall, there is a further decline in mental status, and individuals may die of cardiac arrest.
During cold exposure, the body can generate heat through shivering and conserve heat by vasoconstriction of the peripheral blood vessels. For an athlete, exercise is also a mechanism to generate body heat. Because of differences in their intrinsic physiology or differences in body fat, children and older adults will chill faster than young and middle-aged adults. As a group, men will chill faster than women. For an adult who is not swimming, the neutral water temperature that will allow maintenance of a stable core body temperature is approximately 32-34 C. For adults who are swimming (at a moderate pace, for up to 60 minutes) the neutral water temperature is approximately 21-25 C (70-77 F). For harder or shorter efforts, the neutral temperature may be substantially lower. Swimmers will become hypothermic at a rate which is proportional to the duration of immersion and the difference between the neutral temperature and the ambient water temperature.
Once the core body temperature falls during cold water immersion, it may continue to fall even after removal from the water, in a condition known as afterdrop. In a classic study of non-wetsuit swimmers in San Francisco Bay, 5 of 11 swimmers developed hypothermia after a swim of up to 45 minutes in 53 F water on New Year’s Day. In 10 of the 11 swimmers, there was a significant decrease in the core body temperature after emerging from the water, over a period of of up to 30 minutes. After a long, cold swim, athletes should exercise special caution during the 1st transition and the beginning of the bike portion.
The possibility of hypothermia during open water swimming is what prompted the use of wetsuits for triathlon events. By adding insulation and allowing the body to conserve heat, the wetsuit effectively lowers the neutral water temperature for any given open water swim. Each of the various governing bodies has developed policies about water temperature and the use of wetsuits.
At the other end of the temperature spectrum, hyperthermia results when the core body temperature is elevated. In medical circles, we use the term fever to characterize a mild to moderate rise in the core temperature. While there’s no official definition, we might choose >38 C to indicate a fever. With hyprethermia due to heat exposure, the body’s temperature can continue to rise to >40 F and heat stroke can result. Symptoms include an increase in the heart rate and respiratory rate, muscle weakness or cramping, and eventually a deterioration in the level of consciousness. The human body responds to hyperthermia by sweating and by dilating the peripheral blood vessels and allowing heat to transfer more easily to the environment. It is easier for the body to transfer heat to surrounding air than to surrounding water.
For adult men who are immersed but not swimming, the core body temperature has been shown to increase during prolonged exposure to water temperatures of 36-37 C. For adults who are swimming at moderate intensity, the core body temperature may increase in water temperatures of 28-32 C (82-89 F). These facts are the basis for having an upper limit of water temperature for which wetsuit use is allowed and safe.
Water Temperature Guidelines for Other Organizations
The issue of safe temperatures for open water swimming events has long been controversial. The several governing bodies for open water swimming have each studied this issue and developed their own guidelines in recent years.
USA Swimming, the national governing body for swimming in the United States in 2011 developed a comprehensive list of safety recommendations following the death of American open water swimmer, Fran Crippen, during a race held in the United Arab Emirates in very warm water. Included were changes to USA Swimming’s water temperature guidelines. Citing from the USA Swimming rules for open water swimming (2013 Rulebook):
FINA, the international governing body for the aquatic sports (swimming, diving, synchronized swimming, water polo, and open water swimming) sets the minimum allowable water temperature for open water swimming at 16 C (60.8 F) (see FINA 2013 Open Water Swimming Rules). In June of this year, FINA adopted a new rule governing the maximum temperature allowable for open water swimming events. At the recommendation of its Technical Open Water Swimming Committee, FINA has now set the maximum allowable temperature at 31 C (87.8 F). This new rule came under almost immediate criticism because it is less restrictive than the current USA Swimming limit of 85 F.
For additional context, FINA specifies the allowable water temperature for swimming pool events to be between 25 and 28 C, and recognizes that athletic performance falls off at water temperatures greater than 27 C.
The International Triathlon Union (ITU), the international governing body for the sport of triathlon, has adopted water temperature safety guidelines that also account for the race distance and the air temperature. All swims should be cancelled for water temperatures <13 C and all long distance swims (3000m or 4000m) should be cancelled for water temperatures <14 C. Races can be shortened depending upon the air and water temperatures (see the 2013 ITU Competition Rules). For age group athletes, the use of a wetsuit is forbidden above 22-24 C and is mandatory below 14-16 C, depending upon the race distance.
World Triathlon Corporation (WTC), the owner of the Ironman brand events, announced their SwimSmart initiative in May of this year. For their North American Ironman events, WTC adopted a safe temperature range of 52 to 88 F. If the water temperature is outside that range, the swim portion of the event will be shortened or cancelled. For all of their events, wetsuits are permitted for water temperatures up to 76.1 F (24.5 C) and prohibited for water temperatures greater than 83.8 F (28.8 C). Athletes wearing a wetsuit when the water temperature is between those cutoff temperatures are not eligible for age group awards.
My Advice
For Athletes. Athletes are usually aware of the rules regarding wetsuit use. They should also be aware of the potential issues of hypothermia or heat-related illness during a race. These new recommendations from USAT provide a framework for critical thinking about this issue. Athletes should use sound judgment and extra caution when participating in events at the extremes of the temperature range. At the low end, extra consideration should be given to the use of a wetsuit even if a race is short. USAT chose not to implement a policy about mandatory wetsuit use, but they do allow race directors to enforce such a rule. My personal view is that swimmers should use a wetsuit for any race where the water temperature is 60 F or less. At the high end of the temperature range, athletes should pay extra attention to their hydration and make certain that their pace or effort is moderated. In the end, only the athlete can make the decision to participate. Water temperature is one factor that should be taken into consideration when athletes make judgments about their safety. If you think it’s unsafe, don’t participate.
For Race Directors. The new recommendations define a very broad neutral temperature range. The vast majority of events will be held in venues where the water temperature will fall into this range. When the water temperature falls outside the neutral range, though, race directors should be very cautious about deviating from the recommendations to shorten or cancel the swim portion of a race. In cold conditions, race directors should give due consideration to requiring athletes to wear a wetsuit. For races at either extreme of the temperature spectrum, race directors should provide athletes with information about hypothermia, heat-related illness, and advice about the use of a wetsuit.
Last weekend’s ESPN Outside the Lines show devoted to triathlon race safety is now available on podcast.
The show included a video report from ESPN reporter, T.J. Quinn and then a panel discussion that I joined along with Dr. John Mandrola and ESPN reporter Bonnie Ford.
If you missed the television broadcast, the podcast would be good listening for any triathlete.