USA Triathlon

New USA Triathlon Water Temperature Safety Recommendations

December 4, 2013 By Larry Creswell, MD 4 Comments

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:

<750 meters, 55-89 F
750-1500 meters, 56-87 F
>1500 meters, 57-86 F.

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):

The water temperature shall not be less than 16 C (60.8 F).
For races of 5K and above, the water temperature shall note exceed 29.45 C (85 F)
The air temperature and water temperature when added together shall not be less than 30 C (118 F) nor greater than 63 C (177.4 F).

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.

Wrap-Up from USAT RD Symposium 2013

January 21, 2013 By Larry Creswell, MD Leave a Comment

I spent the past couple days at the 2013 USAT Race Director Symposium in Colorado Springs. I had the chance to attend last year’s meeting and I’m thankful to the USAT folks for the opportunity to return to this year’s Symposium. Let me share some of the safety-related highlights:

A Common Problem

The Symposium was held at the Cheyenne Mountain Resort in Colorado Springs and the Resort offered van service from the airport. The USAT Symposium was not the only meeting at the hotel, and I shared the van with a woman who was attending a different meeting. We exchanged travel stories and talked about each other’s meetings. When she learned that I’d be speaking about athlete fatalities, she shared that she had a daughter who was a runner and recalled a story about a local athlete who had died during a running race.

The issue of race-related fatalities is obviously not confined to the sport of triathlon.

CPR Class

The Symposium began on Thursday afternoon and included a 2-hour class in CPR. This was an outstanding addition to the program. I took note last year that the organizers of the Boston Marathon, in conjunction with the American Heart Association and American Red Cross, offered a short CPR class for runners, family members, and other supporters at their 2012 event. We all benefit from a high prevalence of bystanders who know CPR. In a comprehensive study of sudden cardiac arrest at half marathon and marathon running events, Dr. Jonathan Kim and his colleagues last year reported that the survival rate was nearly 30%, due entirely to the availability of prompt bystander CPR and prompt defibrillation. This is in sharp contrast to the rather dismal survival rates of ~10% that are typically reported for out-of-hospital cardiac arrest.

Growth in Triathlon

On Friday morning Rob Urbach, USAT CEO, reported on the growth in the sport of triathlon–growth that is represented in the number of participants, annual members, and events. As it turns out, the assembled group of Race Directors represented more than 60% of last year’s races nationally–accounting for more than 350,000 finishers. The growth in our sport is both an opportunity and a challenge. With this growth, we’ll need an ever-increasing commitment to the issue of race safety.

John Korff

Friday morning’s keynote speaker was John Korff, owner and organizer of the New York City Triathlon. He’s a terrific story-teller. And with more than a decade of experience with that event as well as with last year’s Ironman New York race, he had a lot of stories to tell. And while most of those stories were amusing (in a New York sort of way), he also shared a little bit about the personal side of having athlete fatalities in those events.

Race-related fatalities have certainly captured the public’s attention–particularly in large media markets like New York. It’s that attention, particularly after athlete deaths in 2011 that prompted USAT’s recent review of race-related fatalities.

My Talk

I was invited to share with the Race Directors the USAT final report on athelte fatalities during 2003-2011. I’ve written previously about this issue here at the blog and also in a column at Endurance Corner.

I’d call your attention to the final report which is available in its entirety at the USAT website. This is, by far, the most comprehensive look at the issue of event-related fatalities in triathlon. And while there may well be questions that still deserve our investigation, there is a bunch of useful information to help guide us as we try to improve in the area of race safety. It’s useful reading for athletes, race directors, and virtually anbody involved in the sport.

The last 2 pages of the final report outline a vision of Shared Responsibility for Race Safety, where athletes, event organizers, and USAT all have a role. For each of these groups, there is a concise set of recommendations that may help to reduce the fatality rate going forward. I truly believe that all of the viable strategies that are likely to have a favorable impact are included in that short list.

Safety Planning

We heard from Andy Emberton, Operations Manager, Communications Director, and Risk Manager for World Triathlon Corporation (WTC), the folks that own the Ironman series of races. Andy offered very practical advice for incident management (including fatalities among others) and explained in detail how careful event and safety planning were essential. An ounce of prevention! It’s clear that WTC has placed an emphasis on race safety and has gained tremendous experience over the years with large, long-distance triathlon events in a large number of venues throughout the world.

Bill Burke

The Saturday program included a great talk by Bill Burke, the owner of Premier Event Management in New Orleans. Bill has had the opportunity to serve as race director for a bunch of large, high profile races including the New Orleans 70.3, Nation’s Triathlon, Hy-Vee Triathlon, Escape from Alcatraz Triathlon, New York City Triathlon, Ironman New York, and the Olympic Trials for 2004 and 2008, among others.

He also has a unique history of having dealt with 10 athlete fatalities at his races over the years. When I’ve talked with groups about the issue of race-related fatalities, I’ve often worried that the discussion of statistics often removes the human side of this issue. Bill did a terrific job of describing the very human aspects of these tragic events. He told the individual stories of 8 of those athletes, sharing a little bit about their athletic and personal history together with the details of how their race-day deaths unfolded. You couldn’t help but have a tear in your eyes. For the assembled Race Directors, he shared his insights about careful event and safety planning as well as interacting with surviving family members after the incidents.

A Few Thoughts

All organized sports, and particularly the endurance sports, will continue to need to address the issue of event-related fatalities. Organizations such as the International Marathon Medical Directors Association and USA Swimminghave issued reports on this topic. As the scientific community continues to learn about the causes–and opportunities to prevent–sports-related sudden cardiac arrest, we should work to incorporate these findings in our efforts to improve race safety.

USA Triathlon Fatality Incidents Study

October 26, 2012 By Larry Creswell, MD 6 Comments

Yesterday, USA Triathlon (USAT) released a report entitled “USA Triathlon Fatality Incidents Study.” The report details the experience with race-related fatalities at USAT-sanctioned races and events from 2003 through 2011.

I’ve written previously here at the blog (August 2011 and January 2012) and also in my column at Endurance Corner about my involvement this past year with this USAT project.

While the report may leave some questions unanswered and might stimulate further investigation, this represents the most detailed look yet at this issue. The facts are presented along with recommendations for improved race safety, centered around a theme of “shared responsibility”–where athletes, race directors, and USAT all play an important role.

The report is worthwhile reading. I hope that you’ll read the report and share the findings with your family members and fellow athletes.

Race Safety and USA Triathlon

January 17, 2012 By Larry Creswell, MD 4 Comments

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.

Ahead

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.