Margo Mountjoy - Safety in open water swim

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FINAITUWorkshoppSafetyinOpenWaterSwimDr.MargoMountjoyIOCMedicalCommission/FINAWORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentFINA H l h & S f G id liFINAHealth&SafetyGuidelinesC R tCaseReportAquaticEnvironmentFloraandFaunaAquaticEnvironmentAquatic EnvironmentAquaticEnvironmentPollution: AirPollution:AirAquatic EnvironmentAquaticEnvironmentPollution: WaterPollution:WaterAquaticEnvironmentWaterQualityInfectious diseaseInfectiousdiseaseGastroenteritis reportedinsomelocationsaftermarathonswimeventsAquatic EnvironmentAquaticEnvironmentCLIMATE:CurrentsAquaticEnvironmentCLIMATE:SurfAquatic EnvironmentAquaticEnvironmentCLIMATE: wind / air temperatureCLIMATE:wind/airtemperatureAquaticEnvironmentqCLIMATE:watertemperature hypothermiaAquatic EnvironmentAquaticEnvironmentCLIMATE:watertemperature hyperthermiaAquatic Competition EnvironmentAquaticCompetitionEnvironmentCrowdingC di KONA I MCrowding:KONAIronManTraumafromCrowdingWORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentFINA H lth & S f t G id liFINAHealth&SafetyGuidelinesCaseReportSafetyRecommendationsAthlete InterventionsAthleteInterventionsSafetyRecommendationAthletePeriodicHealthEvaluationSafety Recommendation: athleteSafetyRecommendation:athleteAdequate Athletic TrainingAdequateAthleticTrainingSafetyRecommendation:athleteAppropriateEventPreparationSafetyRecommendation:athleteAdequate AcclimatizationAdequateAcclimatizationtime zonestimezoneslocaldietilieventmilieuenvironmentalfactorsaltitudetemperaturepeventspecificsSafetyRecommendations:athleteRacedaynutritionandhydrationstrategiesSafetyRecommendationsEventInterventionsSafetyRecommendations:E t i t tiEventinterventionsPreapprovedsitespecificpp pSafetyActionPlanSafetyRecommendations:EventinterventionsAppointmentofaFederationSafetyDelegate(FSD)whoisindependent of the Host Organizing Committee (HOC) to oversee theindependentoftheHostOrganizingCommittee(HOC)tooverseetheimplementationoftheracedaySafetyActionPlanAppointmentofaHOCSafetyOfficer(HOCSO)AuthorityvestedintheFSD,theHOCSOortheChiefRefereetopostpone,cancel,ormodifyaneventwheresafetyconditionsp p y ywarrantSafetyRecommendations:EventinterventionsM d t tt d f Athl t t tiTechnicalMeetingMandatoryattendanceofAthletesrepresentativesSafetytopicstoinclude:explanation of the course layout and hazardsexplanationofthecourselayoutandhazardstides,currentsorotherwaterconditionsmarinelifeweather conditionsweatherconditionswatertemperaturewaterqualityconditionslocation of safety craftlocationofsafetycraftdescriptionofmedicalsupportonsiteandavailabilityofhospitalcaresignalforhelpfloatonbackandraisehandforassistanceevacuationplanforclearingtheracecourse,includingdescriptionofp g , g prelatedvisualandaudiblesignalsAshortpreracesafetybriefing,mandatoryforallathletesSafetyRecommendations:EventinterventionsMonitoring And Rescue Of SwimmersMonitoringAndRescueOfSwimmers (a)Eachswimmershallbeunderthedirectobservationofatleastone HMF/OCSafetyCommitteeMemberorRefereeatalltimesduringtherace.The configurationofthecoursewilldeterminewhereSafetyCommitteeobserversared 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 TwowayradiosorothercommunicationSafetyRecommendations:EventinterventionsMonitoringAndRescueOfSwimmersSafetyTeam:qualifiedandexperiencedpersonnelRaceCourseConfiguration tomaximizeobservationofathletesbysafetyteamN b i fi i f b hNarrowbasinconfiguration safetyteamcanbeonshoreAthleteMonitoring:athletedesignatedescortcraftvs.zoneobservationSafety craft designated to monitor athletes separated from the packSafetycraftdesignatedtomonitorathletesseparatedfromthepackDesignatedevacuationcraftq400mwithAED/lifesupporttrainedresponderon the field of playonthefieldofplayDesignatedrescuelandingpointsalongthecoursewithlifesupportequipment& trained personnel&trainedpersonnel2waycommunication withdedicatedprivatechannelamongstallofthesafetyteamand chief refereeandchiefrefereeSafetyRecommendations:EventinterventionsSafetyRecommendations:EventinterventionsAccountingforSwimmersClearidentificationofathleteracenumberonbodyDesignatedofficialtoaccountforallathletesatbeginningandendofrace(regardlessoftypeofathleteexit)( g yp )Utilization of electronic tracking technologyUtilizationofelectronictrackingtechnologyElectronicTrackingTechnologyg gySafetyRecommendations:EventinterventionsWater QualityWaterQualityFreeofhazardousobstaclesanddangerousmarinelife,currents&tidesCertificateofwaterpurityissuedbyapublicauthoritywithin72hoftheraceSafetyRecommendations:EventinterventionsWaterTemperatureMeasured 2h prior to the event at 40cm depth at midcourseMeasured2hpriortotheeventat40cmdepthatmidcourseMeasuredbyFederationSafetyDelegate+HOCsafetyOfficerRemeasured at 1h intervals during the raceRemeasuredat1hintervalsduringtheraceSafetemperaturerange:>16CandSafetyRecommendations:EventinterventionsSafetyRecommendations:EventinterventionsMedicalServicesAppointmentofaqualified&experiencedchiefmedicalofficeAppointmentofqualifiedemergencysupportstafffor the medical facility and fieldofplay athlete monitoringforthemedicalfacilityandfieldofplayathletemonitoringMedical facility to include:Medicalfacilitytoinclude:emergency&traumaequipmentAEDAEDheating/coolingcapabilitiesAmbulance orhelicopterforathleteevacuationonsiteSafetyRecommendations:EventinterventionsSafetyduringTrainingFullathletesurveillanceandsafetyprogram duringy p g gtrainingsessionsgpreracewarmupspostracewarmdownspSafetyRecommendations:EventinterventionsCourseEvacuationPlanEventSafetyPlantoincludecourseevacuationplanforallathletesandracepersonnelPractice it!!!Practiceit!!!WORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentFINA H lth & S f t G id liFINAHealth&SafetyGuidelinesCaseReportCase ReportCaseReportFrancesCrippen1984 2010Case Report: Fran CrippenCaseReport:FranCrippenUSANationalTeam6 time US National Champion: 800m/ 5k and 10k6timeUSNationalChampion:800m/5kand10kSilver medals (400m/ 1500m) Pan Am GamesSilvermedals(400m/1500m)PanAmGamesld d l kGoldmedal10kPanAmGamesBronzemedal10kFINAWorldChampionshipsSilver10kPanPacificChampionshipsFranCrippenCase ReportCaseReportMedical HistoryMedicalHistoryl hHealthyExerciseinducedasthmaNofamilyhistoryofsuddendeathNoPHE(ECG)onfileCaseReport:FranCrippenF 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 fromoceanfloor2haftertheconclusionat300mfromfinishCaseReport:FranCrippen3athletestransportedtohospitald h fl d f d h dTreatedwithIVfluidsfordehydrationComplaintsof:dizzinessmuscle crampsmusclecrampsfatiguel l igeneralmalaiseNotemperaturesrecordedCaseReport: ClimacticConditionspFranCrippen Airtemperature: 35CWatertemperature:29C(?)Humidity:4674%Waves:nilTides:nil(lagoon)Windspeed:nilVisibility:goodCaseReport:Fran CrippenFranCrippenCauseofdeath:MultipleFactorsp? cardiac potential existence of cardiac abnormality[HCM and?cardiac potentialexistenceofcardiacabnormality[HCMandundetectedchannelopathies notbeexcluded]?uncontrolledEIAinunfavourablerace/environmentalconditionscannotbeexcludedHighphysicalexertionandfatigueinconjunctionwithhighairg p y g j gandwatertemperatures,potentialdehydration,andheatexhaustion leadingtoprogressiveincapacitationandiunconsciousnessSUMMARYPreventingInjury&IllnessthroughAquaticSafetyEnvironmentalqualityAdequateathletescreeningSafetyeducation:athlete&personnelHealth&safetyplanEffectiveathletetrainingAcclimatisationSupportofresearchneedsThank you for your attention!Thankyouforyourattention!Questions?Discussion?Discussion?Dr.MargoMountjoyg j yIOCMedicalCommissionFINASportsMedicineHyperandHypothermiaBergeron 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.HyperthermiaInwater,heatlossisthedirectresultofheatconvectionbetweentheskinandthewaterHeatlossinwateris25xgreaterthaninairofthesametemperatureHyperthermiacannotoccurinwaterbelow31CFactorsAffectingBodyCoreTemperatureAmbientairtemperatureHumidityyWindWatercurrentsWatertemperature*Intensityofswimming*D ti f *Durationofexposure*PropertiesofsportuniformType of swimmingTypeofswimmingSubcutaneousfatthicknessthelargerthecoretoskininsulation,theslowerg ,therateofheattransferLOCMethodstoDecreaseRiskofHeatInjuryFacilities(aircondition/coolmist)SchedulingSchedulingMonitoringofenvironmentalrisksDevelopmentofenvironmentalparameters/rulesAdequate education of athletes/ support personnelAdequateeducationofathletes/supportpersonnelMedicalactionplanforhypo/hyperthermiaAthleteMethodstoDecreaseRiskofHeatInjuryAcclimatisationWarm up & PrecoolingWarmup&Pre coolingHydrationClothingClothingAcclimatisationProgressive physiological adaptations to improve exerciseProgressivephysiologicaladaptationstoimproveexerciseheattolerance&safetybyexercisinginnaturaloutdoorhot ambient conditionshotambientconditionsA minimum of 12 weeksAminimumof1 2weeksIndividual responses are highly variableIndividualresponsesarehighlyvariableSuccessful heat acclimatisation increases work capacity inSuccessfulheatacclimatisation increasesworkcapacityinhotenvironments&reducesexertionalheatillnessriskHypothermiabiAmbienttemperatureWindWetclothingWater temperatureWatertemperatureCurrentsHypothermia: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 waterswimmingMarshN,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 upTreatmenteat e tWarmingSwimmingInducedPulmonaryEdema(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;35:18390SIPESIPEEPIDEMIOLOGYscuba divingSYMPTOMSseveredyspneascubadivingbreathholdingdivingenduranceswimmingcoughsputumproductionHemoptysis(50%)Casestudies:n=70/60 NochestpainPATHOPHYSIOLOGYOverperfusion iscausedbytheincreaseinambientpressure,peripheralvasoconstrictionfromambientcold,andincreasedpulmonarybloodflowresultingfromexercise.Highpulmonarycapillarypressuresleadstoextravasationoffluidintotheinterstitium.Resultsinhypoxemiaandsecondarypulmonaryedema.SIPESIPEMECHANISMThe physiologic effects of immersion, swimming in the semisupine position with the headThephysiologiceffectsofimmersion,swimminginthesemi supinepositionwiththeheadandshouldersabovewater,thusincreasingthepressuredifferencebetweenthelowerextremitiesandthethorax,andtherelativelycoldwatertemperature,allservetoincreasetheriskofexerciseinducedpulmonaryedema.p yPREDISPOSITIONPREDISPOSITIONRiskfactorsareunclear29%recurrencerateAffected individuals are typically healthy males and femalesAffectedindividualsaretypicallyhealthymalesandfemales.OlderindividualsmaybeathigherriskSIPEMEDICALMANAGEMENTRadiographoftenshowstypicalappearanceofpulmonaryedemaSpirometry demonstratedrestrictivelungfunction,whichpersistedforaweekManagementissupportive,withoxygenthemainstayoftreatment.Diureticshavebeenused,buttherearenodataastotheirefficacyNif di i h b d b h i l d l idNifedipine hasbeenusedtopreventrecurrence,butthereisonlyanecdotalevidenceCasesusuallyresolvewithin24hoursLongtermsequelae:unknownWORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentE id BEvidenceBasetemperature:hyperthermia/hypothermiaacutepulmonaryedemaHealth&SafetyGuidelinesResearchStudyCase ReportCaseReportResearchNeedsDeterminationofsafewarmandcoldwatertemperaturesDetermining the influence and interrelationships of otherDeterminingtheinfluenceandinterrelationshipsofotherenvironmentalfactors,includinghighandlowambientairtemperature,humidity,wind,waves,andcurrents.Determiningoptimalstrategiestobetteracclimatizeathletestoaquatic environmentalchallengesIdentifyingobjectivesignsofdevelopingexertionalheatillnessineliteaquaticathletesDeterminingandquantifyingfactorsaffectingathleteadaptationtoandheattoleranceinwater.Furtherstudyonthermalparametersandtheearlysignsandsymptomsofdehydrationand/orhyperthermiawiththeuse of a wetsuit in hot ambient temperaturesuseofawetsuitinhotambienttemperaturesFINA/IOC/ITUResearchProject1) 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 2727CC 2020CCRange of Tw: Range of Tw: 3232C, C, 2727C, C, 2020CCSwim duration Swim duration 2020min, min, 6060min, min, 120120min min With and without heat loadingWith and without heat loadingObjective and subjective measuresObjective and subjective measuresj jj jSt d d iSt d d iStudy designStudy design2020 swimmers/triathletesswimmers/triathletes20 20 swimmers/triathletesswimmers/triathletes13 males 7 females13 males 7 femalesAge 24.5 Age 24.5 7.2yr7.2yrHeight 175 3Height 175 3 9 5cm9 5cmHeight 175.3 Height 175.3 9.5cm9.5cmMass 75.26 Mass 75.26 9.5kg9.5kgt tt t 3232 11CCwater temp water temp 3232..11CCambient tempambient temp 3030CCambient temp ambient temp 3030CCrrelative humidityelative humidity 5656%%rrelative humidity elative humidity 5656%%rradiant heat loadadiant heat load 400400 800800 wmwm22rradiant heat load adiant heat load 400400--800 800 wmwm22Rectal temperature via inRectal temperature via in--situsituRectal temperature via inRectal temperature via in situ situ thermistorthermistorSwim speed and Swim speed and ddistanceistanceRatings of perceived exertionRatings of perceived exertionRatings of perceived exertionRatings of perceived exertionThermal sensation & discomfortThermal sensation & discomfortOverall feeling stateOverall feeling stateValidated scoring systemValidated scoring systemmmethodsethods 22mmethods ethods 22Fitness Fitness economy measure economy measure (kJ/km) using respiratory gas (kJ/km) using respiratory gas exchangeexchangeexchangeexchangeAv Av distdist swum: swum: 1357m (20min), 3737m (60min), 8131m 1357m (20min), 3737m (60min), 8131m (120min)(120min)Av paceAv pace (100m(100m--1)1) : 88: 88 15s; 9815s; 98 14s; 9014s; 90 14s14sAv pace Av pace (100m(100m 1)1) : 88 : 88 15s; 98 15s; 98 14s; 90 14s; 90 14s14sTTReRe increase consistent for all 3 swim durationsincrease consistent for all 3 swim durations(38.1 (38.1 38.538.5C) C) Rate ofRate of TT increase greatest for 20min swimincrease greatest for 20min swimRate of Rate of TTReRe increase greatest for 20min swimincrease greatest for 20min swimPositive linear relationship between Positive linear relationship between TTReRe & perceived & perceived pp ReRe ppthermal discomfortthermal discomfortNegative relationship between actualNegative relationship between actual TT & overall feeling& overall feelingNegative relationship between actual Negative relationship between actual TTReRe & overall feeling & overall feeling state state 13Unbearably HotA12Extremely HotA1011emperature Very HotHot9eivedBodyTeWarmHot8Perce32deg20min32deg60minSlightly Warm7 32deg120minNeutralSlightly 637.2 37.4 37.6 37.8 38.0 38.2 38.4 38.6CoreTemperature(C)SlightlyCoolPerceived v actual body temperaturePerceived v actual body temperature910Extremely UncomfortableB8Very67omfortVery Uncomfortable45ThermalDisco32 d 20 iUncomfortable34T 32deg20min32deg60minSlightly Uncomfortable12 32deg120minComfortableMM t tt t i f h fi f h f137.2 37.4 37.6 37.8 38.0 38.2 38.4 38.6CoreTemperature(C)Co o tab eMean core Mean core temperarturetemperarture rise for each of rise for each of 3 3 swimsswims2.0C1.01.532deg20minFairly good0.5elingg32deg60min32deg120min0.50.037.2 37.4 37.6 37.8 38.0 38.2 38.4 38.6OverallFeeCoreTemperature(C)Neutral1.0Fairly Bad2.01.5Overall feeling for Overall feeling for 3 3 swims @ swims @ 3232C TC Tww2.0gg @@ ww3030C C TTambambC l i t d tC l i t d tConclusions to dateConclusions to datesswimmers appear to tolerate Tw ofwimmers appear to tolerate Tw of 3232CCsswimmers appear to tolerate Tw of wimmers appear to tolerate Tw of 3232 C C under laboratory conditionsunder laboratory conditionsswimmers self perception of heat/stress swimmers self perception of heat/stress li blli blappears reliableappears reliablethermodynamic thermodynamic modellingmodelling has potential has potential to accommodate individual variabilityto accommodate individual variabilityyy It is not possible to agree upon a finite water temperature at which the Itisnotpossibletoagreeuponafinitewatertemperatureatwhichthesafetyofeveryopenwaterswimmercanbeguaranteedundereverycircumstance. Rules,regulationsorobjectivemeasuresoftheaquaticenvironmentwillneverbeasurrogateforthecombinedvigilanceofcoaches,athletesupportstaffandraceofficials.pp Thewellbeingofallopenwaterswimmersremainsacollegialresponsibility.p y DavidGerrard ViceChairVice Chair FINASportsMedicineCommittee December2012WORKSHOPOVERVIEWHealthrisksoftheaquaticenvironmentE id BEvidenceBasetemperature:hyperthermia/hypothermiaacutepulmonaryedemaHealth&SafetyGuidelinesResearchStudyCase ReportCaseReport