Limiting Deaths in Triathlon

August 13, 2012

Here’s what happens. An RD says, “I’m going to charge you a fee, and for that fee I’m going to deliver among other things a safe environment in which you can race. Let’s shake.” The contestant says, “On behalf of my family, it’s a deal. I’m going to trust you with my life and health. In consideration, I’m going to do my part, which is to understand the rules, prepare properly, and race safely. Here’s my hand on it.”

As an RD, whether you have 35 or 3500 people in your race, you are making this commitment 35, or 3500, times, to each of these people who’ve agreed to take part in the fruit of your inspiration. It is because I understand the gravity and weight of this compact that I have so much respect for race directors. If you are an RD, you place your own peace of mind on the line to grant peace of mind to others, which makes you our sport’s most august stakeholders. Let’s talk about some things that might help you increase the likelihood of successful and uneventful swim legs in the triathlons you produce.

Before we do that, I’m going to address all your customers and some of your vendors, to make sure they are properly equipped to perform their part of the agreement.

There are third and fourth parties to this transaction. One is the national governing body, i.e., the sanctioning body. USA Triathlon lists three core values, one of which states, “We value safety,” and one assumes this is not only a value, but part of its mission. It’s reasonable for the athlete to assume that this patina of extra underwriting is a part of the bargain into which the athlete enters, and part of the trust in which he can rest. To that end, USAT announced last year the formation of a study group to investigate deaths in triathlon. Two and a half months ago it announced that its study had been concluded, and a report was generated and disseminated to “medical professionals, race directors, athletes,” with the promise that upon final review the report and recommendations would be made public. I, for one, am anticipating the release of this report along with the recommendations that attend it. There are certain important elements of course design and best practices the details of which I will only gloss over tangentially, pending the publication of USAT’s recommendations.

Then there’s the licensing body. If you’re a 70.3, or Ironman, or Life Time Fitness affiliate, or Challenge affiliate, or you’re part of IMG’s Challenger World series, or the like, then you and your race represent a brand, and these brands stand for things. One such “thing” is, one assumes, a protocol, a checklist, a list of best practices, that attend these races, and into which the contestant can rest further, and assume he’s in good hands on race day.

As many of you know, we’ve had what seem frequent deaths in the swim leg of the triathlon in recent years. I’ve been a triathlete for more than 30 years, and for this sport’s first generation a death used to be a rare event. Now it seems almost routine. It’s at least partly because: 1) Triathlon is a much bigger sport, and 2) We have a much greater facility for news.

Let’s attach some numbers to this. Triathlon experiences a death roughly once per 75,000 race occurrences, that is, if there are 50,000 of us, and we’re each going to do 1.5 races a year, on average one of us is going to die in a triathlon during that year. I don’t know if we should consider that a lot of deaths, or whether these deaths are a relative and acceptable rarity. As a comparison, that number is about 1 in 100,000 in a marathon, 1 in 300,000 in a half-marathon. Most of the deaths in triathlon occur in the swim and most, but not all, occur from heart attacks. Therefore, the actual number of heart attack deaths in triathlon is not at great variance with that rate in marathons.

One hypothesis is that the increase in participants means that we’ve scraped the surface of really fit athletes who “belong” in triathlon, and we’ve gotten down to a layer of the population who’re racing because it’s fashionable, the assumption being that deaths overwhelmingly come from this layer. However, I haven’t seen any evidence to suggest this, and there’s considerable evidence to the contrary. Heart attack occurrences do not seem to attach to newbies, or those who swim inexpertly, or to the less fit.

Is there any reasonable set of dos and don’ts that would serve to decrease deaths? In my view, yes. What can you, as an athlete, do to survive and prosper during the swim? I’m going to limit this discussion to the swim, because deaths in triathlon almost always occur during the swim.

Warm-Up
Can you imagine rolling out of bed, into your car, driving to a 10k footrace, you park your car, walk up to the start, and commence the race without any warm-up? If not, then why do you imagine it’s okay to do this in a triathlon? Now, maybe you don’t warm up for your 10k races. But if this is the case, I can only assume you’re not very competitive—”I race for fun”—and so your warm-up is really the first two miles of the 6-mile race. Fine.

But the swim is not like that. The swim is a cauldron, and the frenetic pace and activity—and your own body’s response to the water—is not anything you are able to entirely control. The swim start in a triathlon is not like the run start in a footrace. The swim takes out much faster than the pace into which swimmers eventually settle, and this is the case with pros and age group racers alike. That’s the tactical dynamic in triathlon. I don’t know, but I would guess that if you were forced to start your half marathon with no warm up, and in an almost dead sprint for the first half-mile, some of the incidences of heart attacks might occur in the beginning rather than at the end.

I always get to a triathlon at least 90 minutes in advance of my start, and when I do I almost always have just enough time and no more. By the time I’m body marked; set my transition area up; take care of my personal moments; make certain I know where the course goes, and the entry and exit of the transition area; take care of additional personal moments (sometimes with a substantial wait in line because the RD saved money on something he should not have scrimped on—see the Port-o-Nazi); and the walk to the swim start; my hope and intent is that I’ll be at that swim start 20 to 30 minutes prior to the commencement of my swim wave.

This is not so that I can swap lies about training totals with my buddies. It’s so that I can get used to the water; raise my metabolism at my rate, rather than at the race’s imperative; so that I can get the blood to my swimming muscles; and so that I can make sure my equipment’s okay (goggles and wetsuit). Okay, there’s a final reason, and it’s just like in a footrace. If I’m warming up in front of the start, then as I compress back toward the start, I’m in the front line. But the very worst place to be is on that front line if you don’t absolutely belong there. You’re just asking for a lot of trouble and grief.

That warm-up may start simply with getting your face and head wet. The natural reaction of your body upon contact with water that is even slightly cold is vasoconstriction, basically, Viagra in reverse. It’s the mammalian diving reflex and the very first response, by your body, when hitting cold water, is brachycardia, i.e., your heart rate slows down. I know what you’re thinking: This doesn’t happen unless it’s cold water. However, we’re just talking wetsuit-legal water. Water temps need to be in the 70s before this reflex is not triggered. It’s not just your heart rate that changes. Peripheral vasoconstriction occurs, that is, the very muscles that you need in order to swim must get fed by blood vessels that are constricting. I think a lot of people get themselves into trouble in races because they start out, hell bent for leather, with steady-state (rather than warmed-up) bodies hitting the water.

The mammalian diving reflex is most prominent in children, and I don’t know to what degree this occurs in triathletes in their 40s and 50s (the ages I’ve seen most commonly associated with swim deaths in triathlon). So I don’t want to make too much out of it. However, there is a lot that is happening when an athlete first dives into the water and commences his triathlon swim. If there is one likely common element that seems to attend heart attack deaths, whether in footracing or triathlon, it’s an increase in adrenaline. That increase occurs near the end of a footrace, as the athlete anticipates the finish. But it happens in the beginning of triathlons. That’s when the adrenaline rush takes place. If your intent is to cause a heart attack, the very best way to do it is to inject adrenaline into your subject. It therefore seems intuitive to me that if you can spread out the onset of shocking occurrences—face hits water; metered breathing per high effort of exertion; high metabolic effort on a system at rest; the rush of the race start—rather than have them all gang up on you at once, that’s a good thing.

That established, there is no data on whether a warm-up affects one’s ability to survive the swim. We just don’t know whether those who died warmed up or not, except that in certain anecdotal cases where the race logistics do not allow for a warm up. Indeed, there is a school of thought that if more people warm up there will be more deaths in triathlon, because, if the warm-up turns out not to be preventive, then the very fact that we spend more time in the water increases the occurrence of bad things happening while we’re in the water.

I, however, come down on the side of the warm up. As noted one thing we do not see in footraces are heart attacks at the beginning of the race. They almost always occur at the end. While footracers see their heart rates rise gradually throughout the race—and while warm-ups in footracing are routine—heart rates in the swim leg of the triathlon shoot up extremely quickly, and there is not a culture of warming up in triathlon.

Cold Heart, Warm Air
Let us say that you spend this extra 20 or 30 (or more) minutes hobnobbing with your buddies. What’s the air temp? If you’re in a fullsuit, zipped up, in an air temp that’s comfortable when your wetsuit is not on at all, you’re going to start heating up. You might as well go back to your car, sit in the front seat and bake with the windows rolled up.

Here’s what I do. I warm up in the water, which consists of getting my face wet (have you ever seen competitive pool swimmers throw handfuls of water on their faces before mounting the starting blocks?), then a hundred yards of very easy swimming, then 2 or 3 more stretches of increasingly faster swimming that lasts a minute or so. That’s it. That’s all I need. That’s probably all you need. And probably much more than you’re currently doing.

Then I exit the water, and if the air is comfortable with my wetsuit off—and if I’m forced to stand on land a long time before my wave commences—I pull my wetsuit down to the waist, that is, I pull the top of my wetsuit off so that I’m uncovered from the waist up. I only put the suit back all the way on when I’m within about 3 to 5 minutes of the start.

Best is when I can warm up in the water and exit the water with only that amount of time remaining until the gun goes off for my wave. Then I don’t have to take the wetsuit down at all—it’s a bit harder to put on an already wet wetsuit rather than a dry one.

Ideally, if the race is large and has a lot of waves, the RD will have a warm-up area. Unless the air is cold and the wetsuit is needed to be sufficiently warm even on dry land, just pull the bottom of your wetsuit on. Do this in transition, so that you don’t have to get a lot of sand in your wetsuit by trying to put it on while on a sand beach. Pull the wetsuit up just to your waist. Make your way to the beach. Don’t pull the rest of the suit up until you’re ready to warm up, and don’t commence that warm up until 20 or so minutes before your wave is schedule to go. Finish your warm up, and take your place on the start, with your wetsuit still all the way on, no more than several minutes from the swim start. If the start is in deep water, so much the better, as you don’t have the sun beating down on the wetsuit, heating it up, and transferring that heat inside.

What you need to avoid is standing, on dry ground, for 20 or 30 or more minutes, in 80°-plus air temperatures.

Line Up Ability-Appropriate
If you are a poor swimmer, simple: stay out of the way—near the back of the wave or on the side, or both. If you’re a good swimmer, but you still fear being swum overtop, again, simple: line up on the front line, but on the side. If you’re afraid of being swamped with water while breathing, line up on the side that you breathe on, so that nobody is swimming on the side on which you breathe. Just know that this means you might be swimming who-knows-where if you’re not good at holding a straight line, because you have no one in front of you, and no one on the outside of you, on the side on which you breathe.

All this should be calibrated to the size of the field. If you’re in a small swim wave, one or two lines deep, then, not much to worry about. But if you have a whole lot of people lined up behind you, and you’re not a wave-leading swimmer, best move to the side.

If you’re just not a good swimmer, and it’s a big race, you’ll have successive waves of swimmers coming up on you from behind. Best, again, to swim a little aside the main swim corridor.

Wetsuit choice
There are two differences between the wetsuit business now, and when I was in it. First, the business is moving little-by-little away from brick and mortar and expo sales, and more and more toward mail order sales. This means you don’t have the opportunity to try a variety of wetsuits on before making your choice. Second, there seems to be a spate of wetsuits that are torso-short in their patterns. I guess you can add a third factor: You guys don’t have me, and my staff, pestering you about how it is to put on a wetsuit. As a result, a lot of wetsuits—because they’re the wrong size, or the wrong pattern style for the wearer, or because the user didn’t put his suit on correctly—suffer from a lot of shoulder restriction. Become of a student of this particular equipment choice.

Now, I’m going to leave off in my comments to end-users, and direct comments to race organizers.

What You, as a Race Director, Can Do to Provide the Safest Swim
I produced my first triathlon in 1982. I’ve produced individual races; national series; I’ve produced national championships; no-draft and Olympic style; age-group and pro; bike races and triathlons. I have always tried to produce the very best race I could. I'll try to leverage a little bit of what I think I've learned.

As regards swim safety, what we immediately think about are the number and quality of lifeguards and watercraft. Yes, that’s important. It’s vital. However, I’d like to talk about some things beyond what we already know and do well. I’m going to assume that you already understand, for example: 1) Deploy your lifeguards as the race deploys. If you have lifeguards already sitting at the 1k mark of a 1.5k swim before the swim starts, that lifeguard is of very limited utility. If the lifeguards deploy as the race unfolds, and if the lifeguards contract toward the end of the swim as the race finishes, you’ve roughly doubled the usable rate of your lifeguards. 2) Height is huge. Stand-up paddleboards, lifeguard boats—anything that grants height and perspective to a lifeguard—allow him to better scan the swim venue for swimmers in trouble.

But these are the sorts of things you probably already know. I’d like to talk about how you can help keep swimmers out of trouble in the first place.

Warm-up
I have no hard evidence for this, however, I suspect one nexus between deaths in the swim and athlete behavior is the lack of a warm-up. Even if athletes are trained; even if they are experienced; even if they are otherwise healthy; taking off in the water from a cold stop is a shock to the system. This is especially true if the water is cold, but it’s true nevertheless. I’m giving this advice to athletes: warm up prior to the swim. Just get in the water, and get used to the milieu. Get your face wet. Better yet to get the blood to your swimming muscles. Get water in your goggles. Get ready to swim before the start of the race.

Now, if I’m giving this advice to the athletes, but you as the RD do not make accommodation for this, then what are you going to say to your athletes who ask why you didn’t make allowance for a warm-up? I know this might seem harsh, but if I were running USA Triathlon I would deny you a sanction if you did not make some accommodation for a warm-up prior to the start. As I asked the end-users: Can you imagine producing a footrace where you told your customers they could not warm up? At all? Furthermore, I believe that you must not simply provide this area, you should make it very clear to your contestants where the warm-up area is; when and who is allowed in that area at any given time; and when they should exit and take their place proximate to the start. You should deploy some of your lifeguards to the warm-up area.

Keep something in mind that is almost universally overlooked. It is true that most triathletes who die in a race die in the swim. What is truer is that most triathletes who die in a race die in the first event. Recently we saw an unfortunate death in a triathlon in Washington DC when the swim was canceled. Heart attack. Just, it happened during a land-based leg that happened, by accident and necessity, to be the first leg of the race. I think we jump to conclusions when we assume that the swim contains all the peril. Yes, there is peril in the water. But there is also peril that attends a quick run-up to a high heart rate. Hence my concern about what I feel is a cultural problem in the way our sport's athletes prepare for the onset of activity.

Wetsuit practice
A lot of people who think about, study, opine on deaths in triathlon have it in their heads that the wetsuit is to blame. As some know, I have a bit of experience in this. Having incepted the category of “triathlon wetsuit,” and while owning two-thirds of the North American wetsuit market during the 12 years during which I began producing wetsuits and the time I left to found this publication, no one ever died in a Quintana Roo wetsuit. Not one, while selling about 14,000 wetsuits per year. At least, not to my knowledge (and whenever there was a death during the swim leg of a triathlon we checked.) During that period of time, the rubber we used was less stretchy than the rubber of today. The neck junction was, in the beginning, much less comfortable than today. There was nothing about the wetsuits between 1986 and 1999 that were more prone to keep you safe.

Here’s what there was: We were diligent—even naggy—about telling you how to put the wetsuit on; how to take it off; when to take it off; how to know it fit; and how to behave in your wetsuit while you had it on. One thing I’d like to shout from the rooftops, if I could: Unless the air temperature is so low that you need your wetsuit pulled all the way up in order to stay warm enough: Your wetsuit should be pulled down to the waist until your wave is within 3 minutes of leaving! (Unless you allow for a warm-up area, or unless it’s a deep water start.) If the air temp is 80°F and you’re waiting onshore 20 or 30 minutes, fullsuit all the way up, prior to your wave departing, you’re a baked potato, wrapped in aluminum foil, in the oven. By the time you start the race, you’re very possibly overheated. After the commencement of the start of the race, you’re now generating a lot of work, and producing a lot of heat, inside of the oven in which you’ve been baking.

Now, I don’t want to make too much of this. The triathlon wetsuit has certainly brought much more safety to triathlon than it has caused harm or distress. Further, there remains no data that links wetsuits to triathlon heart attacks. However, overheating in a wetsuit does not happen in the swim, because upper-end water temp requirements for wetsuit legality keep that from being a problem. If it happens at all, it happens on land, prior to the commencement of the swim. If you’re an RD, and you have a race with a lot of waves, and you’ve got warm air temps the morning of the race, have your announcer remind folks not to zip up, especially for those wearing fullsuits, if it’s warm and if competitors will eschew warm-ups and wait on-land. Have the starter, with a loudspeaker, remind folks that, unless they’re warming up in the water, wetsuits should be on only to the waist until the swim wave is ready to commence—unless (again) the air temp is cool enough to accommodate wetsuits-up.

In my mind, if you have a larger race, it looks like this: Athletes in corrals, by wave, that move toward the swim start. If the air is warm, wetsuits are not on above the waist until contestants are ready for the warm-up area. When a wave is 15 or 20 minutes prior to its start, those in the wave have access to a warm-up area, which is lifeguard monitored. Wetsuits are now up and all the way on. By the time they finish their warm-ups contestants should be within minutes of the swim start. If they choose not to warm up, wetsuits should not be up until 10 or fewer minutes before the start. If the air temp is cooler, then forget the above. But if it’s warmer, take heed to the above, and form a protocol that takes overheating into consideration.

Keep Your Swimmers as Close to Shore as Practicable
There are two competing imperatives here. In my mind, best to avoid sticking a turn buoy within 100 yards of shore, so that the entire field—regardless of how wide your start is—must bunch up in order to round the buoy and create a traffic jam and a lot of swimmers getting pummeled. If you are forced to do this, explain to your field the dynamics of a turn buoy right after the start, and how weaker swimmers will need to take care, and may best pursue a slightly wider turn. Also, perhaps break your field up into smaller waves, even if you have to split an AG up into two waves.

But sometimes a quick turn is what is required to keep your swimmers close to land. Here’s what’s truest: an immobile athlete (and that’s what an impending swim death looks like, not a panicked athlete, rather an immobile athlete) is not going to survive unless he receives CPR, and then defibrillation, within a very few minutes of his attack. Accordingly, the ability to bring this athlete to shore quickly is critical. Hence, swims that take place closer to shore are more likely to have successful outcomes. Lifeguard boats with defibrillators aboard when swimmers are far from shore is the secondary option.

Consider Waves Based on Ability
This is way outside the box, I know. However, one thing that’s known to any athlete who’s either been a particularly good swimmer, or who’s particularly not, is that it doesn’t take long for fast swimmers to overtake and swarm the back end of prior waves. This means there’s a moment, for a poor swimmer, when the entire complexion of the swim changes. There’s a new group in which this swimmer is now enmeshed, and that group is moving past and through this much slower swimmer and, perhaps, overtop that slower swimmer.

Is there a better way than we now do it? Maybe. One way has been discussed for almost as long as there has been a sport of triathlon, which is to move to a category system, as has been the case in bike racing. However, bike racing is itself moving away from this and toward age-graded racing. But bike racing now seems to work pretty well with a hybrid, giving competitors a choice between the two. It might be good to offer poor swimmers the option of a separate beginner, or BOPer, wave at or near the end of the wave process. Yes, this is going to stretch out your day, and affect your road closures, volunteers, awards, tear down, because you’re sending the slowest athletes off near the end.

An alternative might be waves for the hotshots—open, masters, vets, seniors—prior to the age-grades waves. This would not be unlike the USA Cycling approach, where faster athletes take part in what are similar to categorized waves. So, you might have elite under-40, elite 40-plus, then the age groups. Those who run the Carlsbad 5000 enjoy this approach.

If we can keep our lifeguards focused on watching for the immobile swimmer, I think that’s our best play. It seems likelier that we’ll spot that immobile swimmer if we can spot the obvious change in pace relative to others in the swim wave. If we have all paces represented in that swim wave, it’s harder to notice that immobile swimmer. I therefore think we need to discuss how best for our lifeguards to spot that singular difference in swim behavior and pace, and how course construction, and wave construction, can make that happen.

The Take-Away for All Stakeholders
I think we’ve moved past the point where we simply bat around ideas that might or would make triathlon safer. Those who stand on the consumer side of the handshake agreement need to do their parts. Those on the producer side need not only to do their parts, but to insist that the most appropriate ideas be enshrined into best practices, and have these practices become ministerial, rather than the rare exception to the rule.

This is not to castigate any end-user, or any production or sanctioning entity, for any act it’s committing or omitting right now. Sport, like medicine, like all of industry, like law, is a work in progress. We were not, as a society, negligent before we required seat belts in cars or helmets for motorcycles, or required childhood vaccination—we just got better at health and safety. There’s a constant tension between safety and freedom, personal responsibility and regulation. Sometimes we don’t know what to regulate, or even to recommend, until we have enough data upon which to act. Consider our back-and-forth for a generation on whether fluid replacement beyond pure water is best; whether hyper-hydration is a prudent idea or a recipe for hyponatremia; whether we should preemptively hydrate during a race or drink only when thirsty; whether to rely on purely carbohydrates during a race or whether hunger satiety requires fats during in-competition fueling.

As a consequence—and because my recommendations are largely based on my experience and intuition, with little hard evidence supporting them—I can appreciate any reluctance to change behavior. Nevertheless, there are a lot of safety elements to our races commonly accepted now that we embrace simply because they’re intuitive. There are no studies that suggest we should plug our handlebars, nevertheless we do. Accordingly, I’d like to hear the counter-arguments to what I’m recommending. If both consumers and producers make no changes in our behavior—if we keep doing what we’re doing, we’ll keep getting what we’re getting. We all must decide whether 1-in-75,000 is the best we can do.

I applaud USA Triathlon for the study it has commissioned. I eagerly look forward to its results. I have not, in this article, gotten into the tall weeds of course and wave construction, lifeguard training, what kinds of watercraft are most appropriate, where defibrillators should be deployed, and so forth, because I think USAT’s recommendations may cover much of this.

Regardless of what side of that handshake agreement we’re on—consumer, producer, media—asking ourselves whether we can do more on behalf of those stakeholders to whom we are responsible it seems to me more than just a healthy exercise.