Triathlon Safety, ESPN Outside the Lines, and Me

I had a chance today to be a panelist for an episode of ESPN's Outside the Lines that will be broadcast on Sunday morning at 8 am Eastern on ESPN2.  The show is devoted to triathlon safety, particularly as it relates to the swim portion of races.  I joined host, Bob Ley, ESPN reporter, Bonnie Ford, and Louisville, Kentucky electrophysiology cardiologist, John Mandrola for a discussion about race-related fatalities and efforts to improve race safety.  I appreciate the opportunity and I hope you can tune in on Sunday.
ESPN this afternoon posted a related on-line article by Bonnie Ford, entitled "Trouble Beneath the Surface."  I wasn't given a chance to read the article before the TV show taping.  I wish I'd had that opportunity.  At any rate, I tweeted the link for the article earlier this evening and I'm sharing the link here as well.  The story is good reading for any triathlete.  The article continues to bring attention to the problem of sports-related sudden cardiac death.  As a triathlon community we need to have an ongoing discussion about this problem.
Also posted online--and used as an introduction to the OTL show--is a ~9-minute video clip by ESPN reporter, T.J. Quinn.  As a means of introducing the topic, the video clip uses the tale of 46-year-old Ross Ehlinger who died during the swim portion of this spring's Escape from Alcatraz Triathlon.  The tale is poignant.  It's a very personal look at the tragedy through the eyes of the Ehlinger family.  I participated in that race and I've written here at the blog about my experience that day.
But reading through the "Trouble Beneath the Surface" article, I see that I might have a different take on a few things.  And maybe I can fill in some gaps.  Here are some of my thoughts:
How Big is the Problem?
Any death at a triathlon is a tragedy.  But fatalities at triathlon races are very rare.  Based on USAT's 2003-2011 data, that risk is about 1 per 75,000 participants.  In other words....if your local annual triathlon had 200 participants each year, you could reasonably expect to have a fatality every 150 years.  I've lived near the Mississippi River for 26 years now.  Those numbers remind me of planning for the "100-year flood."  And I know that many communities don't prepare for the 500-year flood.
In the past couple years, I've heard the entire range of reaction to this risk.  At one end of the spectrum is the person who says that even a single fatality is too many....and that we simply shouldn't have triathlon.  At the other end of the spectrum is the person who says that when the risk is only 1 per 75,000, we should devote our energies to solving other, more common problems.
Somewhere in between those extremes, we need to find a way forward.
What's Known About the Cause?
The article, video, and upcoming OTL show focus on the swim.  Indeed, most race-related deaths have occurred during that portion of the event.  But not all.  Perhaps 25% have occurred during bike or run portions--or even after the race is completed.
The common thread seems to be cardiac arrest.  We know from autopsy reports in triathlon victims as well as running race victims of cardiac arrest that there is an underlying (almost always unsuspected) heart abnormality in the vast majority.  And that turn's out to be the situation in Ehlinger's case.  His autopsy findings are typical.
We don't yet know what triggers the electrical problem of cardiac arrest during a triathlon.  I suspect that the autonomic (involuntary) nervous system's interaction with the heart plays an important role.  I've written about possible mechanisms and triggers here at the blog.
There is debate about the utility of screening athletes to find such heart abnormalities.  The controversy relates to the expense and the accuracy of the available tests.
But what about the individual athlete--particularly the middle-aged male athlete--who asks the question:  What can I do to reduce my chance of dying at a triathlon?  Given that heart problems are found in upwards of 65% or more of victims, it seems obvious to me that cardiac screening would be the starting point.  I've written about the issue of pre-participation screening here at the blog.  If you're an athlete, you should discuss this with your doctor.
As USAT Event Services Director, Kathy Matejka, pointed out, there will be further investigation about the victims' medical histories, on-scene and hospital treatment, and autopsy reports.  Stay tuned.
Safety In the Water
There's no doubt in my mind that, for most triathletes, the swim portion is the most stressful for the heart.  I bet that if we had heart rate information for large numbers of athletes, we'd find higher heart rates during the swim than any other portion of the race.  That can be a set-up for arrhythmias.
I don't doubt that a warm-up is helpful, from a performance standpoint, to any athlete before competing.  I'm sure it's true for triathlon.  But there is no evidence that a warm-up--or lack of warm-up--has any bearing on the risk of cardiac arrest during a race.  None.  And I'm not aware of data about cardiac arrest in any setting where there's a reasonable hypothesis that an antecedent period of exercise, or warm-up, would mitigate that risk.
The article raises the issue of water temperature and race safety.  Over the years, swimming deaths at triathlon races have occurred in water with temperatures over a very wide range.  No particular temperature appears to be safest.  The various governing bodies related to open water swimming have reached varying conclusions about water temperature and event safety.  USAT is currently considering whether there should be upper and/or lower limits of temperature for races.
The USAT report concluded that the fatality rate was unrelated to the type of race start.  In truth, very few triathlons historically have begun with a mass start.  The Ironman triathlons are one example.  The Ironman races this year has experimented with a variety of start methods to replace the mass start.  The underlying motive was to improve the ability of rescuers to identify an incapacitated swimmer at the start and respond appropriately, if assistance was needed.  That's impossible when 2000+ swimmers start at the same time.  But it's important to note that none of the handful of fatalities during Ironman swims occurred at the very beginning of a race with a mass start.
What Can We Do?
I think that every reasonable strategy for improving race safety and decreasing the chances for a race-related fatality is included in the recommendations from the 2012 USAT Fatalities Report.  If you are an athlete or race director, you should use these recommendations as a checklist.
In the framework of those recommendations, the athlete assumes the responsibility to show up for the race HEALTHY, FIT, and PREPARED.  Nobody can do that except the athlete.  It's critical that an athlete's health, fitness, and preparedness be matched to the demands of a planned race.  In the end, only the athlete can make the decision to participate.
The race director assumes the responsibility to have a robust safety plan.  Nobody can do that except the race director.  It's not that a given number of lifeguards is on duty, but rather that there is a rehearsed plan for identifying the victim of cardiac arrest, rescuing that athlete, and providing CPR and defibrillation within minutes.  This is a formidable challenge.
And as I said on the OTL show, the buck stops with USAT.  It's USAT's responsibility to provide resources, oversight, education, and monitoring.  I give a great deal of credit to USAT for initiating its Fatalities Study, for sharing information about the fatalities, for developing specific recommendations, and for partnering with scientists for current and future studies related to the fatalities.  I'm not aware of a similar commitment by any other foreign or international triathlon governing body.  I suspect we could learn from the worldwide, pooled experience.
Some rambling thoughts!  I could talk about this all night....and maybe tomorrow, too.  Maybe it's just my reaction to having only a few minutes on the OTL show.  Hoping you can tune in on Sunday.