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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
Aquatic EnvironmentAquatic Environment
Pollution: WaterPollution: Water
Aquatic Environment
Water Quality
Infectious diseaseInfectious disease
Gastroenteritis – reported in some locations after marathon swim events
Aquatic EnvironmentAquatic Environment
CLIMATE: Currents
Aquatic Environment
CLIMATE: Surf
Aquatic EnvironmentAquatic Environment
CLIMATE: wind / air temperatureCLIMATE: wind / air temperature
Aquatic EnvironmentqCLIMATE: water temperature ‐ hypothermia
Aquatic EnvironmentAquatic Environment
CLIMATE: water temperature ‐ hyperthermia
Aquatic Competition EnvironmentAquatic Competition Environment
Crowding
C di KONA I MCrowding: KONA Iron Man
Trauma from Crowding
WORKSHOP OVERVIEW
Health risks of the aquatic environment
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
Safety Recommendations: Event interventions
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
Safety Recommendations: Event interventions
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
Safety Recommendations: Event interventions
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
Safety Recommendations: Event interventions
Safety Recommendations: Event interventions
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
Safety Recommendations: Event interventions
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
Safety Recommendations: Event interventions
Safety Recommendations: Event interventions
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 Recommendations: Event interventions
Safety during Training
Full athlete surveillance and safety program duringy p g g
training sessionsgpre‐race warm upspost‐race warm downsp
Safety Recommendations: Event interventions
Course Evacuation Plan
Event Safety Plan to include course evacuation planfor all athletes and race personnel
Practice it!!!Practice it!!!
WORKSHOP OVERVIEW
Health risks of the aquatic environment
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
Health risks of the aquatic environment
E id BEvidence Basetemperature: hyperthermia / hypothermiaacute pulmonary edema
Health & Safety Guidelines
Research Study
Case ReportCase Report
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
Core Temperature (°C)
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
Core Temperature (°C)
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
Health risks of the aquatic environment
E id BEvidence Basetemperature: hyperthermia / hypothermiaacute pulmonary edema
Health & Safety Guidelines
Research Study
Case ReportCase Report