What's killing these triathlon competitors?

Nov 16, 2011

This past summer, at least nine people in the United States died while competing in triathlons, a number that appears to be a record in a sport experiencing a boom similar to what occurred with running in the 1970s. All but one of the nine deaths occurred in the swim portion of the races, and whether nine is a complete count of fatalities isn't known.

Chat with David Brown about how panic attacks might be causing deaths in the swimming portion of triathons, and if there is any way to prevent them. Brown will also chat about other triathlon related topics, from training to the investigations of these deaths.

Do you agree that panic attacks are the likely cause of death? Submit your questions and opinions now.

Related: Deaths in triathlons may not be so mysterious; panic attacks may be to blame

Greetings chatters.  This is a session about the recent spate of deaths in triathlons, nearly all of which occurred in the swim portion of the races. Triathlons are "multi-sport" events in which competitors swim, ride a bicycle, and run, in that order. They range in distance and "sprint" races, in which the swim portion is just under .5 mile to Ironman distance, which starts with a 2.4 mile swim. Eight of the nine people who died in triathlons in the United States this last season died in the swim.

On to the questions!

What's the research behind panic attacks being the cause of these runners dying during the triathlons?

There has been very little research on the cause of death of swimmers in triathlons other than the autopsies that are performed on nearly all the victims. The details of those autopsies are generally not available to the public although the one-sentence "manner and cause of death" generally is.  In my opinion there needs to be some very basic epidemiology done about this problem. What is the sex, age, experience, training, co-existing medical conditions, medications used, etc. in these tragic cases. As to my hypothesis that panic attacks underlie most of them, the first question that needs to be answered is how common panic attacks are among triathletes.  This can only be determined by conducting statistically valid surveys.  I personally think that for at least a while races should have mandatory pre-race meetings in which one of the conditions of getting the colored band on your wrist is filling out anonymously a two- or three-sentence survey about whether the competitor has ever had what he or she considers a panic attack during a race, whether the person has ever had to change swim strategy (such as floating on the back and letting the pack go by) in response to panicky feelings, and whether the competitor has ever aborted a race because of such feelings.

There is a currently very popular saying in medical care circles that "if you don't measure it, you can't change it."  It seems to me that any attempt to try to reduce these deaths begins with measurement.

I trained as a competitive swimmer then competed internationally as a synchro swimmer then got into masters/open water swimmer. When doing the masters/open water swimming, I trained with two squads - a competitive masters swimming group and a tri group. I found that the tri group tended to want to do only freestyle, freestyle, freestyle. Meanwhile, the masters group was doing all strokes and different drills, even if a particular stroke wasn't your specialty. I'm wondering about the benefits of getting tri athletes to train more in backstroke and breaststroke (and maybe even water polo as well) to increase their water skills, and give them more ways to deal with adverse situations e.g.by helping them with sculling, egg beater, back floating, breaststroke on their backs, recovering from unexpected positions in the water etc. People may laugh at synchronized swimming, but one swim instructor commented to me that she was amazed at my comfort in the water. A great sport to teach sighting - lots of freestyle with your head out of the water, and the sculling and egg beater are incredible safety skills, especially for non floaters.

I am speaking entirely anecdotally, but I would say that most triathletes are good enough at alternative strokes (such as backstroke, breast stroke, side stroke) that they probably don't need extra practice and can naturally turn to one of those strokes if necessary. Some of them (breast stroke notably) are hard to do in a wetsuit with long legs. And in most cases I think triathletes would want to get back to freestyle as soon as they feel comfortable.  That said, the better and more versatile a swimmer, the better for handling unexpected things in the water.

Your message that the stigma of panic as a perceived mental illness may indeed be one of the barriers to addressing the swim/triathlon danger. What a fascinating conversation to begin. I applaud you and hope that this is just the beginning. I bet that panic attacks while driving cause daily accidents. Where panic attacks are caused by definable environmental and physical conditions, the path to dealing with them is much easier to see. How to you plan to continue this dialogue?

I have no plans to continue the dialogue per se, although I will be very interested to see where it goes in the triathlon community.  As I mentioned in the newspaper story, USA Triathlon earlier this fall appointed a five-person committee of experts to look in the deaths, their possible causes, and ways that everyone (athletes, race directors, coaches) can possible reduce them. I have learned that Triathlon America, the trade organization for this sport, is also looking into the problem in a very serious way with an eye to coming up with things that people and races can do that might reduce the risk.

Over the years I've noticed that there seems to be a culture among triathletes that the swim leg is something to just survive as opposed to excel at. And because of that, weaker swimmers often are attempting swim portions that barely meet their ability. There also is a lot of fear surrounding open-water swimming in general, even as the sport becomes more popular and training groups become more common. I'm an experienced triathlete and a competitive open water swimmer. Swim starts at open water swim races versus triathlons with open water swims have a very different mood, it seems, because panic is not very common. The swimmers arrive and know what they're getting into. Some wear wetsuits, most do not. Yet at every single open water triathlon I've done (I've done more than 20), I've seen at least 10 people on the verge of panic, some giving up before the race begins. Typically it's because they're not strong swimmers or they do not feel comfortable in open water. Many times they've never practiced in open water or they have not taught themselves to float properly and are clinging to the idea that their wetsuit is a life-saving device.

Do race directors need to take some type of role in providing open water practice sessions prior to the race so that fewer racers are toeing the line in their ill-fitting rented wetsuits for the first time? Providing therapists is a cute idea, but unrealistic for most local races. But if those athletes had chances prior to the race to address their fears for the swim, would that reduce panic?

You make many good points. Certainly people who enter open-water swims (such as the 4.4-mile Chesapeake Bay swim in this area) are more likely to have practiced open water swimming and are probably more comfortable with it than many inexperienced triathletes, some of whom (as you say) view the swim as a necessary evil that will take them to the next part of the race.  Certainly nobody can argue that practice and experience are likely to help, but the interesting thing about panic attacks is that even experienced triathletes report having them, and often after having done many races.  It is interesting to note that the New York City Triathlon (which had two deaths this year and one in 2008) now requires that an entrant attest or promise that they have or will do an open-water swim of a specified length before race day.

Should the race directors stop taking any and all entrants? I was in the NY race three years ago and the mere size of the race field was stress inducing - not to mention waiting for several hours in a wetsuit before our wave hit the water.

Most races already limit the field and sell out early (or, in the case of NYC, rely on a lottery).  Even with limited fields there are always going to be a lot of people in the water at the same time, and people are always going to be excited, and it's always going to be early in the morning, so most of the conditions that may contribute to panic are going to be hard to avoid.

My fiance does a lot of triathlons, so this article hit close to home. What can I do as his supporter to help prevent something like this from happening?

Hard to say. Obviously practicing in the open water wit a wetsuit is essential before one does his or her first race, but it sounds as if your fiance has quite a bit of experience already.  It may sound hopelessly naive, but I think it's good for spectators to tell the person they've come to watch that they shouldn't do anything that seems dangerous just because there's an audience. In other words, it's okay to bail out.  It's a hard lesson for competitors, even run of the mill occasional triathletes to learn, but it's an important one.  There's always another day (except, of course, for these tragic victims in which there wasn't).

When I was younger I spend many a summer swimming in pristine NH lakes. I can relate to your article not because I am a triathlete but because I experienced panic attacks during the first few plunges every summer. Once in the water with unknown depths and all the imagined lake monsters below me... my mind would induce a rapid heart beat, shortness of breath, and all the symptoms you describe. Should athletes look into modified relaxation exercises such as bio-feed back or using breathing exercises to alleviate the mental stress on their bodies during these attacks? As a teen I discovered that if I floated on my back in order to change my focus to a blue sky trimmed with tall trees helped but, my attacks would only subside if I also took long slow breathes to calm my anxiety. Later in life I discovered that this was a form of bio-feed back or self induced relaxation.

I think everyone needs to learn (and perhaps practice) ways to calm themselves down, which is a kind of auto-biofeedback.  Your way sounds like a good one (and a common one).

Did you research or consider the well-known (among local swim team coaches) problem with exercising while holding one's breath (such as lunch capacity training through underwater swimming). Exercising depletes oxygen much more quickly when you're holding your breath, and you can go from conscious to unconscious in an instant. When you in the water, this is a big problem and can lead to drowning. It happened to my nephew (on his swim team), but the coach was there to jump in and resuscitate him.

This is a problem but my impression is it is associated with deep diving, not so much with surface swimming. I also don't think (again, this is just my anecdotal observation) that triathletes in the swim leg are doing a lot of strokes without breathing, as would be the case in a sprint in a pool.

There is another, very unusual phenomenon that I should have mentioned in the article called "swimming-induced pulmonary edema" that has been seen mostly, but not exclusively, in military rescue and combat swimmers. Over-hydration, tight wetsuits (especially in the thigh) and some other things appear to be risk factors for this rare and only now being examined phenomenon. It is possible some of the swimming deaths might have had a component of SIPE in them.

Thanks for writing such a fascinating article! I'm an epidemiologist, so I like your comments from a previous question about the importance of measuring the issue so we can better understand it. Of course, that would also help with getting a handle on possible confounding. I have a number of friends who compete in triathlons and know anecdotally that most of them do not like the swim portion and spend the least amount of time preparing for it. In addition, most are preparing by swimming laps in a pool, versus open water. In your research, how much of that do you think may play a role here in addition to, or in lieu of, panic?

I think many people think pool training is an acceptable proxy for the swim leg of a triathlon, especially a sprint triathlon.  I do not think it is. It is interesting to note that at least four of the deaths this last season occurred in sprint races, the shortest. I think some people are less likely to practice something they're a little scared of. It also isn't that easy to do. You need someone in a kayak or boat to go with you in open water. So it takes some organization.

I am a triathlete and open water swimmer and fairly confident, I have felt the panic come about most often when a swim course is poorly marked. can you comment if disorientation is a factor, in others who panic but don't die?

It's impossible to tell whether disorientation or impeded sight lines played a role in these deaths. I'm sure poorly marked courses don't help. I know from my own experience that in ocean swims (parallel to the shore) in which the swells periodically make the beach invisible it can get kind of scary.

How about tight fitting wet suits, then not being able to breathe? that happened once to me when i borrowed a smaller wet suit.

I do not know if there has been any research on whether there can be actual impedance of the breathing by a wetsuit.  My personal guess would be that wetsuits don't actually mechanically make it more difficutl to breathe. It is the sensation of having something bear-hugging your chest that can be frightening.

I agree with my fellow synchronized swimmer - a totally controlled, gentle swimming environment with nothing but freestyle and tons of space around you - doesn't prepare you for a triathlon start. Synchronized swimmers get kicked by their teammates nonstop as we maneuver during our routines, and we're used to adapting to moving in all different directions. Maybe triathletes should have to train in synchronized swimming. Or water polo. The swim of a triathlon is nothing compared to that.

Interesting strategy. Hadn't really thought that synchronized swimming might be good training for triathlon.

Hi David, Have you considered looking at scuba diving accidents (deaths) for more information. Scuba shares several factors with triathlons: cold water, dark water, tight wetsuits, less skilled swimmers, etc. During my past three dives, I have had inexplicable panic attacks that almost resulted in my drowning - particularly odd, given that I have dove many times. After I had descended quite deep, my heart started to race, and I wanted to tear my scuba mask from my face. I felt as if I couldn't breathe, although, logically, I could. These experiences were frightening, and I'm lucky that nothing came of them - for me. (I commented on your article along these lines, as well.)

I haven't looked into this but I got a number of interesting e-mails from scuba divers relating experiences like yours. There is obviously some similarity, although panic 30 feet down would seem to be a much more dangerous event.

As someone who first started triathlons last year, I think there is something to be said for having to calm yourself down just before getting into the water. Is there any look at if a mass swim start versus a wave or even a time trial start effects participants? The mass swim start routinely involves being kicked, hit and swam over where the other two can be much calmer. My first mass swim starts produced a great deal more fear, anixety and stress on myself than the other two forms. The time trial start is an exciting time, but the anxiety of it seemed a lot less.

I didn't look into the difference between trime trial vs. mass starts. That is another thing that needs to be studied and measured.

Gang, I have to run.  Please be safe, have fun, and don't be afraid to drop out.

In This Chat
David Brown
David Brown, a journalist and physician, has been a staff writer for The Washington Post since 1991. He has covered medical research, the AIDS epidemic, clinical practice, medical ethics, epidemiology, global health, and numerous non-medical scientific subjects. He majored in American Studies at Amherst College, graduating in 1973. He worked as a reporter at The Greenwood (Miss.) Commonwealth and The Baltimore Sun before entering the Medical College of Pennsylvania, from which he graduated in 1987. He works four days a week at the Post and two-thirds of a day at a general internal medicine clinic in Baltimore supervising third-year medical students.
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