margo mountjoy - safety in open water swim

FINA‐ITU Workshopp

Safety in Open Water Swim

Dr. Margo Mountjoy IOC Medical Commission / FINA

WORKSHOP OVERVIEW

Health risks of the aquatic environment

FINA H l h & S f G id liFINA Health & Safety Guidelines

C R tCase Report

Aquatic Environment

Flora and Fauna

Aquatic Environment

Aquatic EnvironmentAquatic Environment

Pollution: AirPollution: Air


Pollution: WaterPollution: Water

Aquatic Environment

Water Quality

Infectious diseaseInfectious disease

Gastroenteritis – reported in some locations after marathon swim events


CLIMATE: Currents

Aquatic Environment

CLIMATE: Surf


CLIMATE: wind / air temperatureCLIMATE: wind / air temperature

Aquatic EnvironmentqCLIMATE: water temperature ‐ hypothermia


CLIMATE: water temperature ‐ hyperthermia

Aquatic Competition EnvironmentAquatic Competition Environment

Crowding

C di KONA I MCrowding: KONA Iron Man

Trauma from Crowding

WORKSHOP OVERVIEW


FINA H lth & S f t G id liFINA Health & Safety Guidelines

Case Report

Safety Recommendations

Athlete InterventionsAthlete Interventions

Safety RecommendationAthlete Periodic Health Evaluation

Safety Recommendation: athleteSafety Recommendation: athlete

Adequate Athletic TrainingAdequate Athletic Training

Safety Recommendation: athlete

Appropriate Event Preparation

Safety Recommendation: athlete

Adequate AcclimatizationAdequate Acclimatization

time zonestime zoneslocal diet

ilievent milieuenvironmental factors

altitudetemperaturepevent specifics

Safety Recommendations: athlete

Race day nutrition and hydration strategies

Safety Recommendations

Event Interventions

Safety Recommendations: E t i t tiEvent interventionsPre‐approved site‐specific pp p

Safety Action Plan

Safety Recommendations: Event interventions

Appointment of a Federation Safety Delegate (FSD) who is independent of the Host Organizing Committee (HOC) to oversee theindependent of the Host Organizing Committee (HOC) to oversee the implementation of the race day Safety Action Plan

Appointment of a HOC Safety Officer (HOC‐SO)

Authority vested in the FSD, the HOC‐SO or the Chief Referee to postpone, cancel, or modify an event where safety conditions p p y ywarrant


M d t tt d f Athl t t ti

Technical Meeting

Mandatory attendance of Athletes representatives

Safety topics to include:explanation of the course layout and hazardsexplanation of the course layout and hazardstides, currents or other water conditionsmarine lifeweather conditionsweather conditionswater temperaturewater quality conditionslocation of safety craftlocation of safety craftdescription of medical support onsite and availability of hospital caresignal for help—float on back and raise hand for assistanceevacuation plan for clearing the race course, including description ofp g , g p

related visual and audible signals

A short pre‐race safety briefing, mandatory for all athletes


Monitoring And Rescue Of SwimmersMonitoring And Rescue Of Swimmers• (a) Each swimmer shall be under the direct observation of at least one• HMF/OC Safety Committee Member or Referee at all times during the race. The• configuration of the course will determine where Safety Committee observers are

d b l h h l• positioned to observe swimmers. For example, in an open race course with no physical• restraints, and depending on the size of the field, it is ideal to have an escort craft with a• designated observer assigned to assure that each swimmer is monitored. However, in• a competition conducted in a narrow rowing basin, it would be impractical to have• individual escort craft on the race course, rather, HMF/OC Safety Committee observers• may be able to follow the swimmers by walking along the shore. In other• circumstances, it may be desirable to organize the HMF/OC Safety Committee• observers by zone. Whenever possible, given the layout of the race course, HMF/OCobservers by zone. Whenever possible, given the layout of the race course, HMF/OC• Safety Committee observer craft (boats or kayaks) should guarantee that all swimmers• separated from

• COMMUNICATION• COMMUNICATION• Two‐way radios or other communication


Monitoring And Rescue Of Swimmers

Safety Team: qualified and experienced personnel

Race Course Configuration to maximize observation of athletes by safety teamN b i fi i f b hNarrow basin configuration – safety team can be on shore

Athlete Monitoring: athlete designated escort craft vs. zone observationSafety craft designated to monitor athletes separated from the packSafety craft designated to monitor athletes separated from the pack

Designated evacuation craft q 400m with AED/ life support trained responder on the field of playon the field of play

Designated rescue landing points along the course with life support equipment & trained personnel& trained personnel

2 way communication with dedicated private channel amongst all of the safety team and chief refereeand chief referee



Accounting for Swimmers

Clear identification of athlete race number on body

Designated official to account for all athletes at beginning and end of race (regardless of type of athlete exit)( g yp )

Utilization of electronic tracking technologyUtilization of electronic tracking technology

Electronic Tracking Technologyg gy

Safety Recommendations: Event interventionsWater QualityWater Quality

Free of hazardous obstacles and dangerous marine life, currents & tides

Certificate of water purity issued by a public authority within 72h of the race


Water Temperature

Measured 2h prior to the event at 40cm depth at mid‐courseMeasured 2h prior to the event at 40cm depth at mid‐courseMeasured by Federation Safety Delegate + HOC safety OfficerRe‐measured at 1h intervals during the raceRe‐measured at 1h intervals during the raceSafe temperature range: >16 C and <31 C



Medical Services

Appointment of a qualified & experienced chief medical office

Appointment of qualified emergency support staff for the medical facility and field‐of‐play athlete monitoringfor the medical facility and field‐of‐play athlete monitoring

Medical facility to include:Medical facility to include:emergency & trauma equipmentAEDAEDheating/cooling capabilities

Ambulance or helicopter for athlete evacuation on site


Safety during Training

Full athlete surveillance and safety program duringy p g g

training sessionsgpre‐race warm upspost‐race warm downsp


Course Evacuation Plan

Event Safety Plan to include course evacuation planfor all athletes and race personnel

Practice it!!!Practice it!!!

WORKSHOP OVERVIEW


FINA H lth & S f t G id liFINA Health & Safety Guidelines

Case Report

Case ReportCase Report

Frances Crippen

1984‐ 2010

Case Report: Fran CrippenCase Report: Fran CrippenUSA National Team

6 time US National Champion: 800m/ 5k and 10k6 time US National Champion: 800m/ 5k and 10k

Silver medals (400m/ 1500m) Pan Am GamesSilver medals (400m/ 1500m) Pan Am Games

ld d l kGold medal 10k Pan Am Games

Bronze medal 10k FINA World Championships

Silver 10k Pan Pacific Championships

Fran CrippenCase ReportCase Report

Medical HistoryMedical History

l hHealthy

Exercise induced

asthma

No family history

of sudden death

No PHE (ECG) on file

Case Report: Fran Crippen

F j i h UAE 23 10 2010Fujairah UAE: 23‐10‐2010

77 i77 competitors

7 5k f ll b k f h l d k7.5km: fell back from the lead pack

8k d hi8km: expressed thirst

9k N ti d t b i i l l9km: Noticed to be swimming very slowly

R d f fl 2h ft th l iRecovered from ocean floor 2h after the conclusion at 300m from finish

Case Report:Fran Crippen

3 athletes transported to hospital

d h fl d f d h dTreated with IV fluids for dehydration

Complaints of:

dizziness

muscle crampsmuscle cramps

fatigue

l l igeneral malaise

No temperatures recorded

Case Report:Climactic Conditions

pFran Crippen Air temperature: 35 C

Water temperature: 29 C(?)

Humidity: 46‐74%

Waves: nil

Tides: nil (lagoon)

Wind speed: nil

Visibility: good

Case Report:Fran CrippenFran Crippen

Cause of death: Multiple Factorsp

? cardiac – potential existence of cardiac abnormality[HCM and? cardiac – potential existence of cardiac abnormality[HCM and undetected channelopathies not be excluded]

? uncontrolled EIA in unfavourable race/ environmental conditions cannot be excluded

High physical exertion and fatigue in conjunction with high air g p y g j gand water temperatures, potential dehydration, and heat exhaustion – leading to progressive incapacitation and

iunconsciousness

SUMMARY

Preventing Injury & Illness through Aquatic Safety

Environmental qualityAdequate athlete screeningSafety education:

athlete & personnelHealth & safety planEffective athlete trainingAcclimatisationSupport of research needs

Thank you for your attention!Thank you for your attention!

Questions?

Discussion?Discussion?

Dr. Margo Mountjoyg j yIOC Medical Commission

FINA Sports Medicine

Hyper and HypothermiaBergeron MF Bahr R Mountjoy M et al International Olympic CommitteeBergeron MF, Bahr R, Mountjoy M, et al International Olympic Committee Consensus Statement on thermoregulatory and altitude challenges for the high‐level athlete. Br J Sports Med. 2012; 46: (11) 770‐9.

Mountjoy M, Migliorini S, et.al. Hyperthermic‐related challenges in aquatics, athletics, football, tennis and triathlon. Br J Sports Med. 2012;46:(11) 800‐4.

Hyperthermia

In water, heat loss is the direct result of heat convection between the skin and the water

Heat loss in water is 2‐5x greater than in air of the same temperature

Hyperthermia cannot occur in water below 31°C

Factors Affecting Body Core Temperature

Ambient air temperatureHumidityyWindWater currentsWater temperature*Intensity of swimming*D ti f *Duration of exposure *Properties of sport uniformType of swimmingType of swimmingSubcutaneous fat thickness

the larger the core‐to‐skin insulation, the slower g ,the rate of heat transfer

LOC Methods to Decrease Risk of Heat Injury

Facilities (air condition/ cool mist)

SchedulingScheduling

Monitoring of environmental risks

Development of environmental parameters/ rules

Adequate education of athletes/ support personnelAdequate education of athletes/ support personnel

Medical action plan for hypo/hyperthermia

Athlete Methods to Decrease Risk of Heat Injury

AcclimatisationWarm up & Pre‐coolingWarm up & Pre coolingHydrationClothingClothing

Acclimatisation

Progressive physiological adaptations to improve exerciseProgressive physiological adaptations to improve exerciseheat tolerance & safety by exercising in natural outdoor hot ambient conditionshot ambient conditions

A minimum of 1‐2 weeksA minimum of 1 2 weeks

Individual responses are highly variableIndividual responses are highly variable

Successful heat acclimatisation increases work capacity inSuccessful heat acclimatisation increases work capacity in hot environments & reduces exertional heat illness risk

Hypothermia

biAmbient temperatureWindWet clothingWater temperatureWater temperature Currents

Hypothermia: Risk of Asthma

Inhalation of cold air during physical activity, can have additional adverse health effects both for asthmatic and healthy athletes.adverse health effects both for asthmatic and healthy athletes.

Epidemiology: (EIA) occur in ≥50% of elite swimmers.

Pathophysiology: Increased ventilation during repeated physical t i i ith lti i i fl ti d i dtraining with resulting airway inflammation and increased parasympathetic activity enhanced by cold exposure

Symptoms: Cough, phlegm, URI exacerbations

Treatment: early inhaled steroids +/‐ inhaled B2agonists prior to exercise [WADA guidelines**]

Hypothermia: Risk of Cardiac Arrythmia

The combination of cold water exposure, voluntary apnoea and face immersion (diving bradycardia) may result in increased sympathetic and parasympathetic activity, possibly causing ventricular premature beats

Cold water itself could be a contributing factor to fatal events in open‐waterCold water itself could be a contributing factor to fatal events in open water swimming

Marsh N, Askew D, Beer K, et al. Relative contributions of voluntary apnoea, exposure to cold and face y p , pimmersion in water to diving bradycardia in humans. Clin Exp Pharmacol Physiol 1995;22:886–7.

Hypothermia: Prevention & Treatment

The effects of cold acclimatisation in humans are minimal

Familiarization with the venue

E t th t h d f tiExposure to the water ahead of time

Sufficient warm‐upSufficient warm up

Treatmenteat e t

Warming

Swimming Induced Pulmonary Edema (SIPE)

Adir Y, Shupak A, Gil A, Peled N, Keynan Y, Domachev L.CHEST 2004; 126:394–9CHEST 2004; 126:394–9

Koehle MS, Lepawsky M, McKenzie DC. Pulmonary oedema of immersion. SPORTS MED 2005 35 183 90SPORTS MED 2005;35:183‐90

SIPE

SIPEEPIDEMIOLOGY

scuba diving

SYMPTOMS severe dyspnea

scuba divingbreath holding divingendurance swimming

coughsputum productionHemoptysis (50%)

Case studies: n = 70/60 No chest pain

PATHOPHYSIOLOGY

Overperfusion is caused by the increase in ambient pressure, peripheral vasoconstriction from ambient cold, and increased pulmonary blood flow resulting from exercise.

High pulmonary capillary pressures leads to extravasation of fluid into the interstitium.

Results in hypoxemia and secondary pulmonary edema.

SIPE

SIPE

MECHANISM

The physiologic effects of immersion, swimming in the semi‐supine position with the headThe physiologic effects of immersion, swimming in the semi supine position with the head and shoulders above water, thus increasing the pressure difference between the lower extremities and the thorax, and the relatively cold water temperature, all serve to increasethe risk of exercise‐induced pulmonary edema. p y

PREDISPOSITIONPREDISPOSITION

Risk factors are unclear

29% recurrence rate

Affected individuals are typically healthy males and femalesAffected individuals are typically healthy males and females.

Older individuals may be at higher risk

SIPE

MEDICAL MANAGEMENT

Radiograph often shows typical appearance of pulmonary edema

Spirometry demonstrated restrictive lung function, which persisted for a week

Management is supportive, with oxygen the mainstay of treatment.

Diuretics have been used, but there are no data as to their efficacy

Nif di i h b d b h i l d l idNifedipine has been used to prevent recurrence, but there is only anecdotal evidence

Cases usually resolve within 24 hours

Long term sequelae: unknown

WORKSHOP OVERVIEW


E id BEvidence Basetemperature: hyperthermia / hypothermiaacute pulmonary edema

Health & Safety Guidelines

Research Study


Research NeedsDetermination of safe warm and cold water temperatures

Determining the influence and interrelationships of otherDetermining the influence and interrelationships of other environmental factors, including high and low ambient air temperature, humidity, wind, waves, and currents.

Determining optimal strategies to better acclimatize athletes to aquatic environmental challenges

Identifying objective signs of developing exertional heat illness in elite aquatic athletes

Determining and quantifying factors affecting athlete adaptation to and heat tolerance in water.

Further study on thermal parameters and the early signs and symptoms of dehydration and/or hyperthermia with theuse of a wetsuit in hot ambient temperaturesuse of a wetsuit in hot ambient temperatures

FINA/IOC/ ITU Research Project

1) What is the effect of the swimming distance1) What is the effect of the swimming distance and the water temperature on behaviouraland autonomic thermoregulation core bodyand autonomic thermoregulation, core body temperature and performance capacity?

2) What early warning signals of altered thermoregulation could be used to gpredict a serious challenge to athlete safety?

3) Can individuals accurately perceive their own

body temperature when swimming in warm water?

4) Is heat tolerance affected by factors including

recent heavy training load illness and specific drugrecent heavy training load, illness and specific drug

use and do swimmers adjust their behaviour accordingly?

FlumeFlume--based studiesbased studies

Fixed water and ambientFixed water and ambientFixed water and ambient Fixed water and ambient temperaturestemperatures

Range of Tw:Range of Tw: 3232°°CC 2727°°CC 2020°°CCRange of Tw: Range of Tw: 3232°°C, C, 2727°°C, C, 2020°°CC

Swim duration Swim duration 2020min, min, 6060min, min, 120120min min

With and without heat loadingWith and without heat loading

Objective and subjective measuresObjective and subjective measuresj jj j

St d d iSt d d iStudy designStudy design

2020 swimmers/triathletesswimmers/triathletes20 20 swimmers/triathletesswimmers/triathletes

13 males 7 females13 males 7 females

Age 24.5 Age 24.5 ±± 7.2yr7.2yr

Height 175 3Height 175 3 ±± 9 5cm9 5cmHeight 175.3 Height 175.3 ±± 9.5cm9.5cm

Mass 75.26 Mass 75.26 ±± 9.5kg9.5kg

t tt t 3232 11°°CCwater temp water temp 3232..11°°CC

ambient tempambient temp 3030°°CCambient temp ambient temp 3030°°CC

rrelative humidityelative humidity 5656%%rrelative humidity elative humidity 5656%%

rradiant heat loadadiant heat load 400400 800800 wmwm22rradiant heat load adiant heat load 400400--800 800 wmwm22

Rectal temperature via inRectal temperature via in--situsituRectal temperature via inRectal temperature via in situ situ thermistorthermistor

Swim speed and Swim speed and ddistanceistance

Ratings of perceived exertionRatings of perceived exertionRatings of perceived exertionRatings of perceived exertion

Thermal sensation & discomfortThermal sensation & discomfort

Overall feeling stateOverall feeling state

Validated “scoring” systemValidated “scoring” system

mmethodsethods 22mmethods ethods 22

Fitness Fitness –– economy measure economy measure (kJ/km) using respiratory gas (kJ/km) using respiratory gas

exchangeexchangeexchangeexchange

Av 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 ±± 14s14s

TTReRe increase consistent for all 3 swim durationsincrease consistent for all 3 swim durations(38.1 (38.1 –– 38.538.5°°C) 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 swim

Positive linear relationship between Positive linear relationship between TTReRe & perceived & perceived pp ReRe ppthermal discomfortthermal discomfort

Negative 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 Hot

A12Extremely

Hot

A

10

11

emperature Very Hot

Hot

9

eived

Body Te

Warm

Hot

8

Perce

32 deg 20 min

32 deg 60 min

Slightly Warm

7 32 deg 120 minNeutral

Slightly 6

37.2 37.4 37.6 37.8 38.0 38.2 38.4 38.6

Core Temperature (°C)

SlightlyCool

Perceived v actual body temperaturePerceived v actual body temperature

9

10

Extremely Uncomfortable

B

8

Very

6

7

omfort

Very Uncomfortable

4

5

Therm

al D

isco

32 d 20 i

Uncomfortable

3

4T 32 deg 20 min

32 deg 60 minSlightly Uncomfortable

1

2 32 deg 120 min

Comfortable

MM t tt t i f h fi f h f

1

37.2 37.4 37.6 37.8 38.0 38.2 38.4 38.6


Co o tab e

Mean core Mean core temperarturetemperarture rise for each of rise for each of 3 3 swimsswims

2.0

C

1.0

1.5

32 deg 20 minFairly good

0.5

eling

g

32 deg 60 min

32 deg 120 min

‐0.5

0.0

37.2 37.4 37.6 37.8 38.0 38.2 38.4 38.6

Overall Fee


Neutral

‐1.0Fairly Bad

‐2.0

‐1.5

Overall feeling for Overall feeling for 3 3 swims @ swims @ 3232°°C TC Tww

2.0

gg @@ ww

3030°°C C TTambamb

C l i t d tC l i t d tConclusions to dateConclusions to date

sswimmers appear to tolerate Tw ofwimmers appear to tolerate Tw of 3232°°CCsswimmers appear to tolerate Tw of wimmers appear to tolerate Tw of 3232 C C under laboratory conditionsunder laboratory conditions

swimmers’ self perception of heat/stress swimmers’ self perception of heat/stress li blli blappears reliableappears reliable

thermodynamic 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• “It is not possible to agree upon a finite water temperature at which the safety of every open water swimmer can be guaranteed under every circumstance.

• Rules, regulations or objective measures of the aquatic environment will never be a surrogate for the combined vigilance of coaches, athlete support staff and race officials. pp

• The wellbeing of all open water swimmers remains a collegial responsibility.”p y

• David Gerrard• Vice‐ChairVice Chair• FINA Sports Medicine Committee• December 2012

WORKSHOP OVERVIEW


E id BEvidence Basetemperature: hyperthermia / hypothermiaacute pulmonary edema

Health & Safety Guidelines

Research Study


margo mountjoy - safety in open water swim

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