Margo Mountjoy - Safety in open water swim

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  • FINAITUWorkshoppSafetyinOpenWaterSwim

    Dr.MargoMountjoyIOCMedicalCommission/FINA

    WORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentFINA H l h & S f G id liFINAHealth&SafetyGuidelinesC R tCaseReport

  • AquaticEnvironment

    FloraandFauna

    AquaticEnvironment

  • Aquatic EnvironmentAquaticEnvironmentPollution: AirPollution:Air

    Aquatic EnvironmentAquaticEnvironment

    Pollution: WaterPollution:Water

  • AquaticEnvironmentWaterQuality

    Infectious diseaseInfectiousdiseaseGastroenteritis reportedinsomelocations

    aftermarathonswimevents

    Aquatic EnvironmentAquaticEnvironmentCLIMATE:Currents

  • AquaticEnvironmentCLIMATE:Surf

    Aquatic EnvironmentAquaticEnvironmentCLIMATE: wind / air temperatureCLIMATE:wind/airtemperature

  • AquaticEnvironmentqCLIMATE:watertemperature hypothermia

    Aquatic EnvironmentAquaticEnvironment

    CLIMATE:watertemperature hyperthermia

  • Aquatic Competition EnvironmentAquaticCompetitionEnvironment

    Crowding

    C di KONA I MCrowding:KONAIronMan

  • TraumafromCrowding

    WORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentFINA H lth & S f t G id liFINAHealth&SafetyGuidelinesCaseReport

  • SafetyRecommendations

    Athlete InterventionsAthleteInterventions

    SafetyRecommendationAthletePeriodicHealthEvaluation

  • Safety Recommendation: athleteSafetyRecommendation:athleteAdequate Athletic TrainingAdequateAthleticTraining

    SafetyRecommendation:athleteAppropriateEventPreparation

  • SafetyRecommendation:athleteAdequate AcclimatizationAdequateAcclimatization

    time zonestimezoneslocaldiet

    ilieventmilieuenvironmentalfactors

    altitudetemperaturepeventspecifics

    SafetyRecommendations:athlete

    Racedaynutritionandhydrationstrategies

  • SafetyRecommendations

    EventInterventions

  • SafetyRecommendations:E t i t tiEventinterventionsPreapprovedsitespecificpp p

    SafetyActionPlan

    SafetyRecommendations:EventinterventionsAppointmentofaFederationSafetyDelegate(FSD)whoisindependent of the Host Organizing Committee (HOC) to oversee theindependentoftheHostOrganizingCommittee(HOC)tooverseetheimplementationoftheracedaySafetyActionPlanAppointmentofaHOCSafetyOfficer(HOCSO)AuthorityvestedintheFSD,theHOCSOortheChiefRefereetopostpone,cancel,ormodifyaneventwheresafetyconditionsp p y ywarrant

  • SafetyRecommendations:EventinterventionsM d t tt d f Athl t t ti

    TechnicalMeetingMandatoryattendanceofAthletesrepresentativesSafetytopicstoinclude:

    explanation of the course layout and hazardsexplanationofthecourselayoutandhazardstides,currentsorotherwaterconditionsmarinelifeweather conditionsweatherconditionswatertemperaturewaterqualityconditionslocation of safety craftlocationofsafetycraftdescriptionofmedicalsupportonsiteandavailabilityofhospitalcaresignalforhelpfloatonbackandraisehandforassistanceevacuationplanforclearingtheracecourse,includingdescriptionofp g , g p

    relatedvisualandaudiblesignalsAshortpreracesafetybriefing,mandatoryforallathletes

    SafetyRecommendations:EventinterventionsMonitoring And Rescue Of SwimmersMonitoringAndRescueOfSwimmers (a)Eachswimmershallbeunderthedirectobservationofatleastone HMF/OCSafetyCommitteeMemberorRefereeatalltimesduringtherace.The configurationofthecoursewilldeterminewhereSafetyCommitteeobserversare

    d b l h h l positionedtoobserveswimmers.Forexample,inanopenracecoursewithnophysical restraints,anddependingonthesizeofthefield,itisidealtohaveanescortcraftwitha designatedobserverassignedtoassurethateachswimmerismonitored.However,in acompetitionconductedinanarrowrowingbasin,itwouldbeimpracticaltohave individualescortcraftontheracecourse,rather,HMF/OCSafetyCommitteeobservers maybeabletofollowtheswimmersbywalkingalongtheshore.Inother circumstances,itmaybedesirabletoorganizetheHMF/OCSafetyCommittee observers by zone. Whenever possible, given the layout of the race course, HMF/OCobserversbyzone.Wheneverpossible,giventhelayoutoftheracecourse,HMF/OC SafetyCommitteeobservercraft(boatsorkayaks)shouldguaranteethatallswimmers separatedfrom COMMUNICATION COMMUNICATION Twowayradiosorothercommunication

  • SafetyRecommendations:EventinterventionsMonitoringAndRescueOfSwimmers

    SafetyTeam:qualifiedandexperiencedpersonnelRaceCourseConfiguration tomaximizeobservationofathletesbysafetyteam

    N b i fi i f b hNarrowbasinconfiguration safetyteamcanbeonshoreAthleteMonitoring:athletedesignatedescortcraftvs.zoneobservation

    Safety craft designated to monitor athletes separated from the packSafetycraftdesignatedtomonitorathletesseparatedfromthepackDesignatedevacuationcraftq400mwithAED/lifesupporttrainedresponder

    on the field of playonthefieldofplayDesignatedrescuelandingpointsalongthecoursewithlifesupportequipment

    & trained personnel&trainedpersonnel2waycommunication withdedicatedprivatechannelamongstallofthesafetyteam

    and chief refereeandchiefreferee

    SafetyRecommendations:Eventinterventions

  • SafetyRecommendations:EventinterventionsAccountingforSwimmers

    ClearidentificationofathleteracenumberonbodyDesignatedofficialtoaccountforallathletes

    atbeginningandendofrace(regardlessoftypeofathleteexit)( g yp )

    Utilization of electronic tracking technologyUtilizationofelectronictrackingtechnology

    ElectronicTrackingTechnologyg gy

  • SafetyRecommendations:EventinterventionsWater QualityWaterQuality

    Freeofhazardousobstaclesanddangerousmarinelife,currents&tidesCertificateofwaterpurityissuedbyapublicauthority

    within72hoftherace

    SafetyRecommendations:EventinterventionsWaterTemperature

    Measured 2h prior to the event at 40cm depth at midcourseMeasured2hpriortotheeventat40cmdepthatmidcourseMeasuredbyFederationSafetyDelegate+HOCsafetyOfficerRemeasured at 1h intervals during the raceRemeasuredat1hintervalsduringtheraceSafetemperaturerange:>16Cand

  • SafetyRecommendations:Eventinterventions

    SafetyRecommendations:EventinterventionsMedicalServices

    Appointmentofaqualified&experiencedchiefmedicalofficeAppointmentofqualifiedemergencysupportstafffor the medical facility and fieldofplay athlete monitoringforthemedicalfacilityandfieldofplayathletemonitoringMedical facility to include:Medicalfacilitytoinclude:

    emergency&traumaequipmentAEDAEDheating/coolingcapabilities

    Ambulance orhelicopterforathleteevacuationonsite

  • SafetyRecommendations:EventinterventionsSafetyduringTraining

    Fullathletesurveillanceandsafetyprogram duringy p g gtrainingsessionsgpreracewarmupspostracewarmdownsp

    SafetyRecommendations:EventinterventionsCourseEvacuationPlan

    EventSafetyPlantoincludecourseevacuationplanforallathletesandracepersonnel

    Practice it!!!Practiceit!!!

  • WORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentFINA H lth & S f t G id liFINAHealth&SafetyGuidelinesCaseReport

    Case ReportCaseReportFrancesCrippen

    1984 2010

  • Case Report: Fran CrippenCaseReport:FranCrippenUSANationalTeam6 time US National Champion: 800m/ 5k and 10k6timeUSNationalChampion:800m/5kand10kSilver medals (400m/ 1500m) Pan Am GamesSilvermedals(400m/1500m)PanAmGames

    ld d l kGoldmedal10kPanAmGamesBronzemedal10kFINAWorldChampionshipsSilver10kPanPacificChampionships

    FranCrippenCase ReportCaseReport

    Medical HistoryMedicalHistoryl hHealthy

    Exerciseinducedasthma

    Nofamilyhistoryofsuddendeath

    NoPHE(ECG)onfile

  • CaseReport:FranCrippen

    F j i h UAE 23 10 2010FujairahUAE:2310201077 i77competitors7 5k f ll b k f h l d k7.5km:fellbackfromtheleadpack8k d hi8km:expressedthirst9k N ti d t b i i l l9km:NoticedtobeswimmingveryslowlyR d f fl 2h ft th l iRecovered fromoceanfloor2haftertheconclusion

    at300mfromfinish

    CaseReport:FranCrippen

    3athletestransportedtohospitald h fl d f d h dTreatedwithIVfluidsfordehydration

    Complaintsof:dizzinessmuscle crampsmusclecrampsfatigue

    l l igeneralmalaiseNotemperaturesrecorded

  • CaseReport: ClimacticConditionspFranCrippen Airtemperature: 35C

    Watertemperature:29C(?)Humidity:4674%Waves:nilTides:nil(lagoon)Windspeed:nilVisibility:good

    CaseReport:Fran CrippenFranCrippen

    Causeofdeath:MultipleFactorsp? cardiac potential existence of cardiac abnormality[HCM and?cardiac potentialexistenceofcardiacabnormality[HCMandundetectedchannelopathies notbeexcluded]

    ?uncontrolledEIAinunfavourablerace/environmentalconditionscannotbeexcluded

    Highphysicalexertionandfatigueinconjunctionwithhighairg p y g j gandwatertemperatures,potentialdehydration,andheatexhaustion leadingtoprogressiveincapacitationand

    iunconsciousness

  • SUMMARY

    PreventingInjury&IllnessthroughAquaticSafety

    EnvironmentalqualityAdequateathletescreeningSafetyeducation:

    athlete&personnelHealth&safetyplanEffectiveathletetrainingAcclimatisationSupportofresearchneeds

    Thank you for your attention!Thankyouforyourattention!

  • Questions?Discussion?Discussion?

    Dr.MargoMountjoyg j yIOCMedicalCommission

    FINASportsMedicine

  • HyperandHypothermiaBergeron MF Bahr R Mountjoy M et al International Olympic CommitteeBergeronMF,BahrR,MountjoyM,etal InternationalOlympicCommitteeConsensusStatementonthermoregulatoryandaltitudechallengesforthehighlevelathlete. BrJSportsMed.2012;46:(11)7709.MountjoyM,MiglioriniS,et.al.Hyperthermicrelatedchallengesinaquatics,athletics,football,tennisandtriathlon.BrJSportsMed.2012;46:(11)8004.

    Hyperthermia

    Inwater,heatlossisthedirectresultofheatconvectionbetweentheskinandthewater

    Heatlossinwateris25xgreaterthaninairofthesametemperature

    Hyperthermiacannotoccurinwaterbelow31C

  • FactorsAffectingBodyCoreTemperatureAmbientairtemperatureHumidityyWindWatercurrentsWatertemperature*Intensityofswimming*D ti f *Durationofexposure*PropertiesofsportuniformType of swimmingTypeofswimmingSubcutaneousfatthickness

    thelargerthecoretoskininsulation,theslowerg ,therateofheattransfer

    LOCMethodstoDecreaseRiskofHeatInjury

    Facilities(aircondition/coolmist)SchedulingSchedulingMonitoringofenvironmentalrisksDevelopmentofenvironmentalparameters/rulesAdequate education of athletes/ support personnelAdequateeducationofathletes/supportpersonnelMedicalactionplanforhypo/hyperthermia

  • AthleteMethodstoDecreaseRiskofHeatInjury

    AcclimatisationWarm up & PrecoolingWarmup&Pre coolingHydrationClothingClothing

    Acclimatisation

    Progressive physiological adaptations to improve exerciseProgressivephysiologicaladaptationstoimproveexerciseheattolerance&safetybyexercisinginnaturaloutdoorhot ambient conditionshotambientconditionsA minimum of 12 weeksAminimumof1 2weeksIndividual responses are highly variableIndividualresponsesarehighlyvariableSuccessful heat acclimatisation increases work capacity inSuccessfulheatacclimatisation increasesworkcapacityinhotenvironments&reducesexertionalheatillnessrisk

  • HypothermiabiAmbienttemperature

    WindWetclothingWater temperatureWatertemperatureCurrents

    Hypothermia:RiskofAsthmaInhalationofcoldairduringphysicalactivity,canhaveadditionaladverse health effects both for asthmatic and healthy athletes.adversehealtheffectsbothforasthmaticandhealthyathletes.Epidemiology:(EIA)occurin50%ofeliteswimmers.Pathophysiology:Increasedventilationduringrepeatedphysicalt i i ith lti i i fl ti d i dtrainingwithresultingairwayinflammationandincreasedparasympatheticactivityenhancedbycoldexposureSymptoms:Cough,phlegm,URIexacerbationsTreatment:earlyinhaledsteroids+/ inhaledB2agonistspriortoexercise[WADAguidelines**]

  • Hypothermia:RiskofCardiacArrythmiaThecombinationofcoldwaterexposure,voluntaryapnoea andfaceimmersion(divingbradycardia)mayresultinincreasedsympatheticandparasympatheticactivity,possiblycausingventricularprematurebeatsCold water itself could be a contributing factor to fatal events in openwaterColdwateritselfcouldbeacontributingfactortofataleventsinopen waterswimming

    MarshN,AskewD,BeerK,etal.Relativecontributionsofvoluntaryapnoea,exposuretocoldandfacey p , pimmersioninwatertodivingbradycardia inhumans.ClinExp Pharmacol Physiol 1995;22:8867.

    Hypothermia:Prevention&TreatmentTheeffectsofcoldacclimatisation inhumansareminimalFamiliarizationwiththevenueE t th t h d f tiExposuretothewateraheadoftimeSufficient warmupSufficientwarm up

    Treatmenteat e t

    Warming

  • SwimmingInducedPulmonaryEdema(SIPE)Adir Y,Shupak A,GilA,Peled N,Keynan Y,Domachev L.CHEST 2004; 126:3949CHEST2004;126:3949Koehle MS,Lepawsky M,McKenzieDC.Pulmonaryoedemaofimmersion.SPORTS MED 2005 35 183 90SPORTSMED2005;35:18390

    SIPE

  • SIPEEPIDEMIOLOGY

    scuba diving

    SYMPTOMSseveredyspneascubadiving

    breathholdingdivingenduranceswimming

    coughsputumproductionHemoptysis(50%)

    Casestudies:n=70/60 Nochestpain

    PATHOPHYSIOLOGY

    Overperfusion iscausedbytheincreaseinambientpressure,peripheralvasoconstrictionfromambientcold,andincreasedpulmonarybloodflowresultingfromexercise.Highpulmonarycapillarypressuresleadstoextravasationoffluidintotheinterstitium.Resultsinhypoxemiaandsecondarypulmonaryedema.

    SIPE

  • SIPEMECHANISM

    The physiologic effects of immersion, swimming in the semisupine position with the headThephysiologiceffectsofimmersion,swimminginthesemi supinepositionwiththeheadandshouldersabovewater,thusincreasingthepressuredifferencebetweenthelowerextremitiesandthethorax,andtherelativelycoldwatertemperature,allservetoincreasetheriskofexerciseinducedpulmonaryedema.p y

    PREDISPOSITIONPREDISPOSITION

    Riskfactorsareunclear29%recurrencerate

    Affected individuals are typically healthy males and femalesAffectedindividualsaretypicallyhealthymalesandfemales.Olderindividualsmaybeathigherrisk

    SIPE

    MEDICALMANAGEMENTRadiographoftenshowstypicalappearanceofpulmonaryedemaSpirometry demonstratedrestrictivelungfunction,whichpersistedforaweekManagementissupportive,withoxygenthemainstayoftreatment.Diureticshavebeenused,buttherearenodataastotheirefficacyNif di i h b d b h i l d l idNifedipine hasbeenusedtopreventrecurrence,butthereisonlyanecdotalevidenceCasesusuallyresolvewithin24hoursLongtermsequelae:unknown

  • WORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentE id BEvidenceBase

    temperature:hyperthermia/hypothermiaacutepulmonaryedema

    Health&SafetyGuidelinesResearchStudyCase ReportCaseReport

    ResearchNeedsDeterminationofsafewarmandcoldwatertemperaturesDetermining the influence and interrelationships of otherDeterminingtheinfluenceandinterrelationshipsofother

    environmentalfactors,includinghighandlowambientairtemperature,humidity,wind,waves,andcurrents.

    Determiningoptimalstrategiestobetteracclimatizeathletestoaquatic environmentalchallenges

    Identifyingobjectivesignsofdevelopingexertionalheatillnessineliteaquaticathletes

    Determiningandquantifyingfactorsaffectingathleteadaptationtoandheattoleranceinwater.

    Furtherstudyonthermalparametersandtheearlysignsandsymptomsofdehydrationand/orhyperthermiawiththeuse of a wetsuit in hot ambient temperaturesuseofawetsuitinhotambienttemperatures

  • FINA/IOC/ITUResearchProject

    1) What is the effect of the swimming distance1) Whatistheeffectoftheswimmingdistanceandthewatertemperatureonbehaviouraland autonomic thermoregulation core bodyandautonomicthermoregulation,corebodytemperatureandperformancecapacity?

    2) Whatearlywarningsignalsofalteredthermoregulationcouldbeusedtogpredictaseriouschallengetoathletesafety?

    3) Canindividualsaccuratelyperceivetheirownbodytemperaturewhenswimminginwarmwater?

    4) Isheattoleranceaffectedbyfactorsincludingrecent heavy training load illness and specific drugrecentheavytrainingload,illnessandspecificdruguseanddoswimmersadjusttheirbehaviour accordingly?

  • FlumeFlume--based studiesbased studiesFixed water and ambientFixed water and ambientFixed water and ambient Fixed water and ambient temperaturestemperaturesRange of Tw:Range of Tw: 3232CC 272...

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