Another sad case of a swimmer’s death occurred during the Naples, FL sprint triathlon. It’s becoming an unsurprising event…if a triathlete dies in competition, there is a VERY good chance that it occurred during the swim.
In this case the triathlete’s neighbor shared the participants concern about completing the swim portion of the tri. She even encouraged him to wear a life vest or arm floaties to do so. The participant, 57 year old Don Green, was pulled from the water while rescuers performed CPR. Sadly he died. I have not investigated any further than this news report, however I wanted to take a few minutes to address YOUR concerns about deaths in the swim leg of a triathlon.
First of all, it’s real. Triathlon deaths occur overwhelmingly during the swim portion of the event. There are a number of “common sense” reasons that this happens, and some information has been collected regarding autopsy results and known previous medical conditions of participants who have died. In the popular press, you may see written that so and so had a known “heart condition”, when in reality the known heart condition is not one that typically causes a “heart attack” as most people understand the term.
Preexisting Heart Conditions and Heart Attacks
Let’s clarify some of terms. A “heart attack” is a laypersons phrase that typically describes anything that causes the heart to stop pumping blood effectively. The most common type of “heart attack” is a myocardial infarction which occurs when a small blood vessel blockage causes the blood flow to a portion of the heart to stop, and an area of heart muscle dies or is temporarily injured. These types of heart attacks almost always cause pain, and usually are not fatal.
When someone with underlying heart disease such as a narrowed blood vessel or previously injured heart muscle exercises, it’s generally a good thing that helps the whole body function in a healthier way. But each individual has a threshold of exercise or activity (sometimes even just walking up the stairs) that creates a demand for oxygen for the heart muscle. If this demand exceeds the ability for the blood to reach the muscle, then it causes pain and “ischemia” or decreased blood flow to a working muscle. This can cause further heart damage in some cases, but is usually reversible almost immediately if the activity is stopped and demand for oxygen goes down. Nitroglycerin, a common heart medication, helps this condition by dilating the blood vessels in the heart allowing more oxygen to flow to the muscle and reducing the pain.
Presumably most triathletes with prior heart attacks would not have such a low threshold for angina to develop and have good blood flow to the heart thanks to procedures such as coronary bypass or blood vessel stenting in which the blood flow to the heart itself is improved with surgery.
There is however, an entirely different category of “heart attack”. I believe that most triathlete deaths occurring due to a “heart condition” or “heart attack” are actually in this category when they occur and I’ll explain why.
Arrhythmias and Athletes
An arrhythmia is an abnormal heart beat, usually a sustained electrical conduction in the heart that results in a rapid heart rate, decreased time for the heart to fill with blood and as a result, a reduced delivery of blood to exercising muscles…and the brain.
Symptoms of an arrhythmia can include rapid heart rate, chest pain and losing consciousness. Most people have occasional abnormal heart beats…and most of us do not feel or notice them. However those that do, frequently experience some concern or anxiety as they can feel the heart pounding or racing. This anxiety can release more stress hormones, which are known to irritate the heart, and cause them to occur more often.
Caffeine is also a culprit and most people who experience sustained arrhythmias are encouraged to avoid caffeine.
Enter the triathlon swim start
Who has NOT experienced stress, anxiety or some panic at some point during a triathlon swim? Even if you are an experienced swimmer with many race starts, the swim start even for pros (or especially for pros) can be an all out “combat” experience at times.
So regardless of your level of swim experience, speed, or place in the field…pro or age grouper, this is the time of the highest adrenaline response. Pre race nerves or anxiety, a cold start, cold water, waves, splashing, no spaces for yourself…
All of that internal adrenaline can contribute to setting off an arrhythmia. While it’s nearly impossible to prove, my suspicion as a physician based on seeing many patients with this condition, is that this may be one of the biggest factors contributing to swim deaths.
There is no place to quickly and easily stop, no way to quickly and reliably signal for help. Even with ample lifesaving kayakers, boarders or noodlers in the water, identifying a swimmer in need is difficult. Compounding that, the swimmer in dire straights may be unable to signal for help or unaware that help is exigently needed until they lose consciousness.
There are surely other contributing factors for swim deaths. A kick to the head causing a loss of consciousness or disorientation, inhaling water causing panic and inability to settle and cough until composure is regained. Fatigue due to struggle. All are factors I’m sure.
However I am willing to bet that the number one factor is the STRESS and ANXIETY and the stress hormones released during the swim start.
Life is not a disposable option when it comes to pride in being a triathlete.
Triathletes and triathlon coaches need to be cognizant of spending the time, money and energy required to create competence and confidence in an open water swim start, so that the likelihood of some avoidable causes of death decreases dramatically.
Terry Laughlin of Total Immersion talks about creating a “cocoon of calm” during the swim. It’s one thing to achieve this cocoon of calm in the pool, in a lane by yourself, but a completely different thing to develop the same skills during a mass swim or even a time trial start.
If you are following along so far, please leave a comment below and let me know what struggles YOU have had in an open water swim start. Let’s work together to make this a safer sport for everyone involved. What’s keeping you from being the best triathlon swimmer you can be?
Ok… not a medical person at all, but your hunches ring true to me. This past September I began an Olympic distance triathlon. The water was quite chilly. I had a difficult time catching my breath. I finally got my breathing barely under control when the race started. The swim start was rather crowded and I have never usually had an issuewith that but the cold water really had me on edge. About 200 yards into the swim I took a kick to the head that knocked my goggles off. I had to stop clear the goggles and try to get moving again. It never happened. I was completely out of rhythm…and my breathing was especially difficult. Rather than push it and risk further distress, I bagged it. I felt horrible because I felt like I quit rather than brute force my way through it. I think I made the right choice… that anxiety of not being able to get my rhythm back was powerful.
Brian, I think you made the right call as well. In my weekly masters practices, especially during the summertime we do a lot of practice with this kind of stuff. Not necessarily getting kicked in the head, but, how to recovery from mishaps, swimming without goggles, fixing goggles mid swim, etc, etc. I’m glad you can tell the story and hope you learn from it for this year!
Cold water is a challenge for me, too. It makes me lightheaded, which makes me start to panic. I have to stop and tread water a bit to regain my composure, even though physically I have plenty of energy.
Stress, tension, and anxiety can trigger a “racing-heart” episode, where the heart increases to 160 or even 200 beats per minute, resulting in decreased blood flow to the brain and unconsciousness. .
During open-water swimming, turning the head to breath with the chance of swallowing water is stressful enough to trigger a “racing-heart” episode, while wearing a front-mounted snorkel reduces this stress by keeping the head stationary and, if wave-water enters the tube, it’s easily blown-out through the purge valve.
Perhaps to reduce stress during triathlon training and racing swimmers should wear a front-mounted snorkel which will reduce chances of triggering a “racing-heart” episode.
I completed my first ever Sprint Tri at the weekend. The swim was in a river (going with the current), mass start with about 300 competitors. We were asked to self draft and knowing I’m not a quick swimmer I waited until at least 2/3 of the swimmers had gone in front of me. Even so I got knocked around a bit, I could not get a rhythm, started taking on water and generally got a bit frightened. So I did breaststroke all the way (virtually) I still drank a lot of water but at least could see over the choppiness and avoid people! I need lots more safe practice in open water.
I suffer from PSVT so your hypothesis makes scary reading! (I didn’t have one in the race though and don’t pass out with them – my plan was to float on my back and signal for help if I was having one).
I too have experienced anxiety as a beginner triathlete. I struggled mightily to complete the swim portion at my first ever race. i basically swam from platform to platform, literally hanging on for dear life. it took me 3 times longer to complete my swim than my typical pool swim.
It has been my experience that the cause of this anxiety is the lack of open water experience. To all triathletes out there, get into open water as much as you can. Familiarity with a variety of open water conditions is your greatest ally.
You will always have pre race jitters, nervousness.
I am an experienced tri athlete now in my 15th season and am training for Ironman Wisconsin. Having only competed in events having ” waves” for the start I am apprehensive as to the mass start an Ironman requires. To all triathletes out there,
it is important have a plan. Swim your own race and race your plan.
I did a triathlon today. It was my third open water water (loch) triathlon. For the first 2 I was slow but fairly calm the whole time.
For some reason this time, possibly because the start was ridiculously crowded, I started to get a bit panicky.
It probably took 500m for me to decide I was going to keep going and not quit the swim, then another 500m to feel comfortable in the water.
My plan is to do more open water swimming in my wetsuit, that way I can used to breathing/moving wrapped in rubber. Not sure how you practice being completely surrounded by other swimmers.
I’ve only done one Sprint Tri and am getting ready for my second, next month. I can’t decide if I’m relieved to read an honest account of the risks of the swim (forewarned being forearmed) or freaked out that maybe it happens more often than I’d thought. (!) In any case, ‘my’ local Sprint Tri is in open water and I remember struggling as it felt people were swimming ‘over me’ which was mildly panic inducing but I was able to manage but worse was getting pushed into the very large, hard buoy/channel marker. That was a doozy. I never felt seriously at risk though as there are a number of friendly rest/rescue kayaks sprinkled throughout. I thought this time I might sacrifice a more efficient route to avoid some of the throng, but haven’t decided yet.
My first sprint was open water Maine ocean. I had done practice swims but, was totally shocked by the cold water in the morning and was unable to fully get my breath for quite awhile. Swimming is my strongest part of the race or so I thought until that moment. Took me a long time to get to the finish of that part of the event.
Can anyone point me in the direction where find a good post about what kind of sportswatch to wear for triathlon ?
Good article. I’m a swim coach and see many triathletes who come to the pool a month before their big event. The open water creates a lot of anxiety. I urge them to adopt swimming as a a regular part of their workouts on a twelve-month basis, but I am often not successful at this. Notes like yours, which do not attempt to hide the risks, may be very helpful.
One way to distinguish “heart attacks” (myocardial infarction) from Sudden Cardiac Arrest (SCA) is: Heart Attacks are a failure of the heart’s plumbing, SCAs are a failure of the hearts electrical system.
Another important cause of death in triathlete swimmers is SIPE, “Swimming Induced Pulmonary Edema.” Extended periods of rapid breathing with the body horizontal, and constrictions across the chest from wetsuits, cause fluid to accumulate in the lungs. These deaths are usually in cold water. I have never heard of SIPE in marathon swimmers or other cold water swimmers who are cold-adapted and do not wear wetsuits..
I am doing my first sprint triathlon this summer and started training last month. Honestly, I am anxious just reading this column and all of your comments. Friends of mine who have done triathlons have told me to hang back at the start and swim on the edges so I am less anxious about getting hit. I don’t know if I will be able to wear a wet suit or not, I am guessing not.
Should I train in open water now with a wetsuit (with a friend on shore of course)? I am generally a strong swimmer and swim in open water when the weather is warmer but I have never raced.