Safe in the Water

What I wrote in Part 1 of this series is that when triathletes die during the swim leg, yes, they drown, but the underlying cause of drowning is — according to a report commissioned by USA Triathlon — usually cardiac arrest or, at least, cardiac arrest accompanies death. However, why did cardiac arrest happen just then? Why not 15 minutes before? Or during the cycling leg? Or the run leg? Or in swim practice a week before? A month before?

In other words, if cardiac arrest is the proximate cause of these drownings, what triggers cardiac arrest precisely when our athletes are in the swim leg of a triathlon?

One obvious difference between race day and typical pre-race swimming, or bike riding, or running, is the use of a wetsuit. It’s often not the case that the wetsuit is used in training, or often in training. It has been surmised that this might be an aggravating factor in sudden cardiac death during triathlons. There are two data points arguing against this. First, the exhaustive USAT report on sudden death in triathlon chaired by Dr. Larry Creswell found that there was no nexus between wetsuits and heart attacks/drownings. Second is my own n=1 experience as a wetsuit manufacturer. We were never able to identify one case of an athlete dying in our wetsuit, and this is over 12 years, and 13,000 to 15,000 wetsuits sold per year.

Of course, we were always very proactive — naggy, even — about how it is our customers should “experience” our wetsuits: how to put them on, take them off, swim in them, how they should fit. It would not surprise me to find out that an extremely ill-fitting wetsuit (especially if it’s extremely overtight) might aggregate with other aggravating factors in some degree or other, in the same way that airline crashes are usually a confluence of problems rather than one particular thing. I would therefore encourage you to get to know your wetsuit in a very personal way, a number of times, well before you race in it, and if it seems to you quite overtight then it probably is.

Panic attacks are often mentioned, and one of USAT’s panel experts — Dr. Jeff Anders — cites this as a possible aggravator. The report’s conclusion states that, “there is no clear evidence that... anxiety/panic... were responsible for deaths during the swim.” Yet, Dr. Creswell characterized adrenalin this way: “If we want to induce cardiac arrest in a patient, we give them a shot of adrenalin.” It is now customary to warn athletes not to sprint for the finish at the end of a marathon, or any race of similar difficulty, unless absolutely trained for it. While marathoners tend more often to die near the end of their event, triathletes tend to die near the start of theirs. The one possible common link is adrenalin. While marathoners start off slow and easy, triathletes start the swim in a dead sprint, in an unfamiliar medium and often in adverse conditions.

To that end, we've written elsewhere about the sorts of things you can do to acclimate to the unfamiliarity of: 1) open water; 2) open water that is cold; 3) open water that is cold, wearing an unfamiliar wetsuit; 4) all of that in a crowd of people crawling overtop while you're trying to breathe; 5) perhaps with large waves or swells; 6) and all of that in an environment that takes you from zero to 60 in nothing flat. If we can, then, reduce the surge of adrenalin through familiarization with your surroundings, visualization, technical training, a warm up prior to the start, prior use of your wetsuit in open water conditions, so much the better. This is not a throw-away paragraph. This is a save-your-life paragraph.

I have a working hypothesis. People tend to die less often in races that scare them spitless. It’s the swims that are treated in the most cavalier fashion that are most likely to cause trouble. I remember standing on the Oceanside pier in 1997, the day before a race of 550 people. Legendary race director and USA Triathlon Hall of Fame member Jim Curl and I produced this race, and the waves were tickling the underside of the pier. That pier is very, very high above the water. It was a very good surf day for 1 out of 15 surfers, and a very bad surfing day for the other 14, and most of them did not need to be told. Jim and I looked at each other. We didn’t need to say anything — we both knew what the other was thinking.

The next morning, we sent the swimmers off. To quote George Costanza the, ahem, marine biologist, “The sea was angry that day, my friends.” Many just did not start. Many did not make it out through the surf. But there were no incidents. No close calls. No complaints. I think everybody was ready for that swim, in his or her own way. Everybody was either ready to swim, ready to withdraw early into the swim, or ready to say, “No thanks.”

I suspect it’s the people who treat the swim in a cavalier way that find themselves in trouble, for reasons that they do not predict. There are people who do all the training, in a pool — they do all the yards, they swim the race distance in the pool, nonstop — but they cannot conceive of certain things that make open water different. They may never have been in a situation where they cannot see the bottom — they just see blackness. Some people panic in that situation for the first time. They may have completed 1500 meters in the pool, but they always had the edge of the pool, or a lane line, within reach. It may be a different story once you get way out there, and you look at the shore, and it’s a lot, lot farther away than the edge of the pool.

This does not touch on the issue of water temperature, currents that move you away from the direction you intend to swim, or the fact that open water tastes and smells very different than pool water.

Read this article. Read about where to line up in the water, that is, when you are at the starting line whether you should line up in front, behind, or to one side or the other. Understand that hotshots from a subsequent swim wave are going to find you during the swim, and swim past you, through you, over you. Realize that well before that happens, the idiots in your own wave who start too fast are going to do the same thing to you before you’re even 100 yards into the swim (which is a good reason to start to one side). And, for your idiots — you know who you are — if you’re prone to road rage and you just can’t stop yourself, can you leave it on the road, and not bring it into the water?

Do not start out hard. Even if you start easy, you’ll still be going fast. Do not try to alternate breathe, if you’re idea of alternate breathing is every third breath. You can certainly alternate breathe if you want to breathe on one side and then on the other, and I mean immediately on the other. This is an acquired skill, and can come in very handy (Monty and I have written about this extensively on our reader forum here, and have even pointed out — to the amazement of the naysayers — that even the current world’s fastest distance swimmer does this). It’s also handy to be able to swim breathing on either side. You need to be able to survive missing a breath or even two, because that’s going to happen to you from time to time.

For some of us who grew up on the beach, it’s uncomfortable to be asphyxiated underwater but it’s not exactly new. Those of us who grew up riding tall waves are used to getting hung up in a wave, and knowing that, oh well, I’m going to be in this washing machine a little while, there’s no profit in panicking even if my lungs are screaming. The wave is going to end eventually. Disconcerting, yes! But fatal? Only very, very rarely.

The more time you can spend in the open water, the better it’ll be. The less likely you’ll find yourself in an unfamiliar and uncomfortable situation.

I don’t think people are just swimming along in a triathlon — just swimming along — and then, boom, cardiac arrest. This does not pass the test of reasonableness. If this were the case, they’d just die in the pool, during their master’s workouts.

They die in triathlons because of a confluence of things that befalls an athlete all at once. If you combine a strident shot of adrenalin — maybe due to the panic of having another swimmer overtop of you, or through the panic of not being able to see the bottom, or whatever causes you to panic — with a body already under stress and in oxygen debt, along with a heart that is vulnerable or susceptible to cardiac arrest, either through a preexisting anomaly or through a state or occurrence that made that heart temporarily susceptible, then we have a crisis in the making.

If we could just peel off one of those events; if that athlete did not race when sick; if a relationship with a cardiologist or even a general practitioner could have uncovered an underlying problem; if that athlete had more opportunity, or taken more opportunity, to condition himself for the swim task; if that athlete had availed himself of a warm-up pre-race to acclimate to the task; if that athlete executed the swim in some way differently; at a different pace; swimming a different line; if that athlete knew to stop immediately upon the first sign of a significant shortness of breath or chest pain; if we could rewind that tape, what would we find that the athlete could have done differently?

This is not to cast blame on any athlete who has died in the swim. Rather, it’s to cause us to consider: what if that athlete is me? What if that is me, 6 months from now? In retrospect, what could I have done differently? If anything written above strikes a chord with you; if it causes you to schedule time training in open water; if it causes you to wear that wetsuit in open water prior to the race; if it causes you to consider a different wetsuit if yours is extremely tight; if it causes you to see your doctor and to tell him about that shortness of breath or chest pain; if it causes you to get to the start 20 minutes earlier than normal, and avail yourself of a warm-up; if it causes you to become more of a student of the swim, and to consider the swim leg seriously carefully, soberly; if it causes you to stop at the first sign of something obviously abnormal going on inside you; then so much the better. Maybe instead of 4 bad things happening to you all at once, we can reduce that to 3, and you then live to tell the tale.

I think one of the reasons we have deaths in triathlon is that for all our training and preparedness; and for all a race director's preparedness; all parties too often treat a triathlon in terms of the mechanical, efficient execution occurring on race day. I think all sides ought to think of a triathlon as a process and an experience that begins months out and ends at the finish line.

I would like to see race directors do more pre-race. I’d like to partner with them, in a series of emails that might go out starting a couple of months prior to the race, making sure athletes knew the rules during the bike leg, and that they had access to groups that would congregate for open water sessions in the weeks prior to the race. I’d like that series of articles to include an appeal to athletes to think about a relationship with a doctor. If you’re 35-44, you’re more likely to die, believe it or not, of poisoning than anything else. Coronary heart disease is #3 on the list, behind suicide and just in front of road traffic accidents. But the age cohort 45-54 is twice as likely to die of coronary heart disease than by the next mostly likely thing to kill you, which is lung cancer. By the time you’re my age, 56, you’re just as likely to kill yourself, in raw numbers, it’s just that a lot of other causes of death have sprinted past suicide, and heart disease is 9 times more likely to get me than “me getting me”.

Maybe I'm too much the mother hen. Maybe that's my blind spot. But I'd rather have you home to dinner with your spouse and children the night following the race, and I hope you'll forgive a little nagging from time to time. Let’s make sure our hearts are ready for the task, and let’s do what we can to prepare for a safe swim.

Let’s get really granular about what behaviors are proper, versus those that are less well thought out, are innocently omitted, or are downright foolish.

First, let’s talk about what you put in your ears. From Jordan Rapp: “One thing I don't do race morning is listen to music. Why? For two reasons. The first is that I like to make sure I am apprised as soon as possible of important announcements — delays, water temperature, changes to the course, etc. Headphones, in my opinion, are as big a problem in transition as they are on the race course. I also don't listen to music because the last thing I want is something amping me up before the biggest amp I get in a year. When I used to listen to music before rowing races (or big, really important workouts), I would listen to Chopin. Why? Because I had enough adrenalin flowing, and I needed something to counter it. Listen to your favorite "psyche up" song before an Ironman? Bad idea... Likewise, I think this line of thinking should inform race director's choice of music in the transition area. I'm not saying they need to play Chopin (though I wouldn't mind), but I'm not sure I need to hear "Ready For This!" or some other jock jam at 6am...”

Now let’s talk about what you put in your mouth. Be careful of those polls on the right hand side of the page. They’re usually there for a strategic reason. My I reference one of those polls? Ten percent of you are Red Bull patrons; 4 percent are Monster fans; 3 percent 5 Hour Energy drinkers; and only 62 percent of you say you never consume these. At least a fifth of you are regular consumers. I would warn against the cumulative quantity of all the beverages, gels, and so forth that you might not realize all contain caffeine and who knows that else. And, by all means — I’m sorry I even have to mention it, but I know you people — you aren’t both caffeinating and drinking alcohol on race morning are you?

There are some pretty good things you can put in your body. It seems as if people are typically, or at least often, low in magnesium, and electrolytes in general and magnesium in particular is a pretty good idea during the days leading up to the race. Hyponatremia does kill athletes, and that’s the combo of clear water with a distinct lack of electrolytes. Rapp again: “You see this folks carting around gallon jugs of water the day before a race. I'd like to see folks start taking 4-6 SaltStick caps mandatorily the day before the race and forget about the ‘drink lots’ part of hydration.”

There is a real controversy over whether hearts that give out during an athletic competition — especially in us older folks, and I’m talking now about athletes over 45 — are damaged hearts, or whether we do something that takes our otherwise healthy hearts and pushes them over the edge.

My answer is, “yes.” Yes to both. Not because I have good evidence, because, really, there is no good evidence. If you talk to a dozen cardiologists (and I have) they’ve each got an inkling, but there is not a clear consensus between them. This frees me up to speculate.

For years, a lot of us who’ve been doing triathlon for a long time knew that we weren’t simply putting wear and tear on our knees, but also on our hearts. Now, finally, after hearing from the medical and scientific community that we were imagining things, we know that the incidence of atrial fibrillation is higher in long term endurance athletes than in the general population.

I don’t know that medicine knows with any clarity what sorts of things we might have done to ourselves over the years that predisposes us to trouble. Not to put too fine a point on it, but I find it notable and ironic that ventricular hypertrophy is variously considered a good thing (athlete’s hearts are healthier, right?) and also a marker for pathologies. All this aerobic work has helped keep our plumbing clean and healthy, but what has it done to the pump?

I do not believe that our friends and fellows have hearts that just decide to stop specifically during our swim legs. One theory is that it’s a rush of adrenalin that aggravates an already stressed situation, which includes an acute lack of oxygen for the task at hand. That lack of oxygen is certainly caused by too much work for the oxygen available, which in turn might be caused by either the high early pace of the swim, the lack of acclimation granted you by a sufficient warm up, or both. Add to that the missing of one or two consecutive breaths, which causes another surge of adrenalin, and, whammo.

Now, before you cardiologists say, “Yes, of course! It’s not a heart anomaly! It’s a sudden adrenalin rush! Nix all the talk about cardiac testing!” Dr. Larry Creswell, a cardiologist who chaired USAT’s panel on death in triathlon, believes that an adrenalin rush is the final push that throws our athletes into a critical situation, but he still believes in heart screening. My main reticence to even the notion of heart screening is that it will cause you to take, or continue to take, a cavalier attitude toward your race preparation and execution. It is my firm suspicion that if you die in the swim leg of a triathlon, it was not a fait accompli. It was not simply, “your time.” Rather, it was your behavior, combined possibly with the behaviors of those around you — which in a way flows back to you, if you had an opportunity to inoculate yourself in some ways from that bad behavior of others — that triggered or contributed to your crisis. It’s not that you behaved badly. It’s that you behaved in a way that many athletes behave, in all good conscience, none of us the wiser, but in a way that was nevertheless in retrospect unoptimized for survival and prosperity.

In our next installment we'll talk about what race directors might do to lessen the possibility of a tragedy occurring in the water.

[Images by the incomparable Timothy G. Carlson]