Triathlon-Related Deaths - The Facts and What You Should Know

by Larry Creswell, M.D.

Last August I volunteered to help with a USA Triathlon (USAT) review of race-related fatalities in recent years. Since this issue has been in the news these past couple weeks with athlete deaths at the inaugural Ironman New York triathlon and again at the USAT National Championships in Burlington, Vermont, I thought I’d share my experience with the review, some data you might find interesting, and some thoughts about a path toward better race safety.

My partners on the USAT Medical Review Panel included Richard Miller, MD, a trauma surgeon at Vanderbilt University; Stuart Weiss, MD, an emergency medicine physician who serves as the medical director for the ING New York Marathon as well as the New York and Ironman New York triathlons; Rob Vigorito, a long-time race director for events including Eagleman 70.3; and Bill Barnett, a race director for several New England events. Everybody in the group is an athlete and each of the race directors had first-hand experience with a fatality at one of their races.

Our charge was to review information about all of the event-related fatalities at USAT-sanctioned events from 2003-2011, analyze the data for patterns, and organize the data so they could be shared easily. A second phase of the project is still underway. The data from our review have been shared with a broad constituent group in American triathlon -- athletes, event directors, USAT officials, physicians, event directors. USAT is now in the process of collecting feedback. There will be a report forthcoming that presents the data along with recommendations about how to improve race safety.

Never before have I spent an entire year focused on learning about one very specific problem like this. I’ve learned a lot. The stack of articles I’ve read -- both in the popular and scientific press -- is pretty tall. In scientific circles, there hasn’t been much written about triathlon fatalities, but there is a considerable and growing body of material about this issue in other sports. By best estimates, more than 4,000 athletes die each year in this country from sports-related sudden cardiac arrest (SCA). Virtually no sport or form of exercise is spared in that regard. The International Marathon Medical Directors Association and USA Swimming have recently issued recommendations about the prevention of SCA in running and swimming events, respectively.

I’ve also learned a lot through discussion -- with triathletes and family members; race directors whose events were involved; USAT administrators and race officials; experts in pre-hospital care of cardiac arrest victims; experts at the condition known as immersion pulmonary edema (IPE); participants in bystander CPR and resuscitation for athlete victims; an attorney specializing in risk management for national sports governing bodies; an athlete who himself had been successfully resuscitated after cardiac arrest while swimming; and many, many others. From virtually everyone concerned, I’ve heard how unsettling these fatalities have been for our triathlon community.
We shared a preliminary look at the data at the USAT Race Directors Symposium held in Colorado Springs this past January. Some highlights:

The overall fatality rate for USAT-sanctioned events is approximately 1 per 75,000 participants. For comparison, the risk of SCA at long-distance running events is approximately 1 per 100,000 participants in marathons and 1 per 300,000 participants in half marathons.
There were 45 fatalities, including 1 victim at a training camp and 1 spectator death (due to a bike crash). Male victims outnumbered female victims, roughly paralleling their participation rates in triathlon. All age groups have been affected except teenagers.
Of the remaining 43 athlete fatalities at races, 5 were traumatic (all from bike crashes) and 38 were non-traumatic (due to a medical cause).
Of the 38 non-traumatic deaths, 30 occurred during the swim, 3 during the bike, 3 during the run, and 2 after the race. All but 1 of these 38 occurred due to SCA; the other was due to a pre-existing metabolic syndrome and hyperthermia.
Although the proximal cause of SCA could not be established with certainty in each victim, it appears that “typical” drowning or unusual medical problems (such as stroke, seizure, syncope, IPE) were not likely responsible. The most plausible explanation is a sudden, fatal arrhythmia -- a primary cardiac problem.

We can dispel some common misperceptions:

This is not a problem of beginners and is not a problem with swimming ability.
The fatality rate has not increased in more recent years. The number of fatalities has paralleled the growth in participation rate in triathlon.
The fatality rate is not related to using/not using a wetsuit.
The fatality rate is not related to the type of swim start (mass, wave, time-trial). No particular start method appears to be safest.
The fatality rate is not related to the length of the race.

I don’t want to preempt USAT’s final report on this issue, and I honestly don’t know at this point what form it will take and when it will be made public, but I’d like to share my personal view about a path forward. I see this as an issue of shared responsibility.

The Athlete’s Responsibilities

Show up at the race healthy. Have an annual physical examination focused on heart health. In conjunction with your doctor, consider additional cardiac screening with EKG, echocardiogram, or stress testing, depending upon your circumstances. Pay close attention to warning signs such as chest pain, unexplained shortness of breath, and blacking out or unusual light-headedness, and seek medical evaluation for these problems.
Show up at the race fit and prepared. Your selection of a race and your approach to the race should match your preparation.
During the swim portion of a race, be vigilant. At the very first sign of distress (which might manifest with chest pain, shortness of breath, coughing, unexplained fatigue or weakness, lightheadedness), immediately STOP and seek help. Your life could well depend upon receiving assistance. Err on the side of quitting.

The Event Director’s Responsibilities

The swim course should be designed with safety as a foremost consideration. The farther the course takes athletes from the safety of shore, the more difficult it will be to rescue a victim of SCA.
The safety plan must be extraordinarily robust for the swim portion of the event. The time window for successful resuscitation of the victim of SCA is only a handful of minutes. Survivability drops off greatly with each passing minute. There must be a plan that allows for near-instant recognition of the lifeless victim, rescue from the water and provision of CPR promptly, and defibrillation within just a few minutes. An on-water communication system may be essential for coordination of these rescues.

Larry Creswell, M.D., is a cardiac surgeon and Associate Professor of Surgery at the University of Mississippi Medical Center in Jackson, Mississippi. In addition to his regular column on Endurance Corner, he maintains The Athlete's Heart blog to offer information about athletes and heart disease in an informal way and to encourage exchange and discussion that will help athletes build a heart-healthier lifestyle. You can contact him at lcreswell@umc.edu.