Is this a problem in open water swim races?
If not whats the difference. How about the "senior games" swim events, they have some longer swims any problems there ?

ok.

are you sure he knew why his posts were taken down? did he respond to your statement that the autopsy on the death in NY is not complete?

Hi Dan,
Do you plan to post updated info on the cause of death for the two athletes, once known?
Thanks, John

"are you sure he knew why his posts were taken down?"

i am not entirely sure about this but i think the person might be a she. the answer to your question is, i don't know. if you just paper the forum board and you don't read or care about the responses to what you're writing, then, maybe not. however, when you're banned, and the response to the ban is to go around it by setting up a new user account, that's not the typical response by those of goodwill finding themselves unable to post.

and before you ask, we get dozens of new users ever day. i have to disable many of them. every day. this is because of the spam, and the folks who come on the board for their own commercial reasons. so, no, i don't send a love note to everyone. i don't take the time to educate everyone on what they're doing wrong. that's what the sticky thread and the faq is for.

been doing this for better than a decade. somehow, 50,000 of you have found a way to post here without falling afoul of me. if you find yourself banned, it's very probably your own fault, and something you very likely could have forestalled.

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Dan Empfield
aka Slowman

That's a good question. I can see someone seeing their post disappear, thinking they did something wrong or that the system was broken, and then re-posting. Of course, it is possible Dan gave him ample warning, in which case reposting under a different name was pretty stupid.

Aside from the speculation about the cause of death that Dan mentions above, the fist person account was pretty compelling. I've been wondering about what SIPE symptoms are like and that account was very descriptive.

So Dan, now that you've posted the offending content, how about posting the non-offending content - the first-person content

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blog
twitter

I can't speak for slowman, but there was another thread that was briefly on the front page and promptly deleted that had a long discourse on the death, and still mentioned SIPE, so if he is clear, he's ignoring it and registering new accounts to do so (This was posted by a registered today with 1 post person).

John

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Top notch coaching: Francois and Accelerate3 | Follow on Twitter: LifetimeAthlete |

There was mention in an article about OWS races as well, yes.

I saw one of the original posts and was glad to see it was pulled...

"Do you plan to post updated info on the cause of death for the two athletes, once known?"

i don't know if i'll attach specific causes of death to each athlete who dies in a triathlon. what we will do here is post the results in the aggregate, that is, out of the X number of deaths in triathlon over the past decade, Y have been for this reason, Z for that reason, and so forth.

then, armed with actual fact, we'll lay out a set of best practices, and we'll focus on these things:

ATHLETE BEST PRACTICES:

1. what tests should you undergo initially, once, to identify congenital problems.
2. what tests should you undergo on a regular basis; how often; how much should these tests cost; who should perform the tests; what these tests won't uncover; and the symptoms that would cause you to want to seek a more expensive test (like a stress ekg).
3. what behaviors can you engage in to desensitize yourself to the impact and violence of the swim.

RACE DIRECTOR BEST PRACTICES:

1. what elements of course design and execution might help to forestall problems in the water.
2. what specific medical plan should you have in place once a bad thing happens. this is really nuts and bolts, such as, how many defibrillators do you have, deployed where? do you ever watch old sea movies, where the captain runs a drill to get the guns ready to fire, or whatever? and he's got a stopwatch and he says, "it took you 3 minutes and 15 seconds! we're going to keep doing this until we can get it down to 2 minutes flat!" it's going to be like that. if you don't get an immobile athlete to shore, or on a boat, and to a defibrillator, within X minutes, then he's gone. so we're going to talk about how, specifically, you try to meet that time target and what best practices allow for that.

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Dan Empfield
aka Slowman

That would be very welcome! I was planning on scheduling an apt with my doc, but I'm done racing for the year so it could wait. Having this info would help with the conversation. Do you plan on including age related variations? Being 50+, are there tests I might consider that a 20 year old wouldn't need?

Thanks,
Victor

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Very good. I appreciate the response and action plan.

Since this seems to be becoming a bigger issue I think that'd be super helpful. Thank you!

I know many are jumping on this issue lately but the most important (interesting points) of this discussion seem to be:

1) Whatever the cause of death is, there doesn't seem to be much in the way of tests or warnings to alert athletes that they are at risk. The heart is a very wild muscle and there are plenty of instances of people getting a clean pass from a heart specialist and dying days later. It's not that anything was misdiagnosed or mistreated, but it just is not easily screened. Look at the people who are dying in the swim. Many are top athletes with no warning signs.
2) Has anyone looked more into the issue of swim warm ups before a race? Most races don't allow it. What impact would warming up have in this debate?

"there doesn't seem to be much in the way of tests or warnings to alert athletes that they are at risk."

not so. we'll be reporting on that.

"Has anyone looked more into the issue of swim warm ups before a race? Most races don't allow it. What impact would warming up have in this debate?"

[facepalm] trying mightily hard not to say anything sarcastic. read here. [/facepalm]

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Dan Empfield
aka Slowman

ideally these deaths would not be bantered about on forums like this at all, with armchair experts saying oh he didnt warm up, undertrained, etc.
But Dan, YOU started the thread about the last death. So really what do you expect?

You must have missed this Slowman post (I highlighted the bits that are obviously relevant):


"you're talking to the wrong person. the person who posted this account - three times - had the benefit of seeing what i'd already posted: that the medical examiner had not ruled on the cause of death in the NYC tri. it was up to that person to stop posting patently untrue statements about the causes of deaths in triathlon. that person chose not to do so.

accordingly, this - to me - calls into question the entire post. if you're willing to make up stuff about others - which is particularly distasteful - then i question the utility of the entire post. we're going to have an appropriate discussion of sudden death in triathlon on slowtwitch.


Dan Empfield
aka Slowman "

if trey miller is around he can talk about it here on this thread intelligently

Thanks for the invitation to participate in the discussion Dan. I haven’t been on here in so long it took me a while to remember my password.

Anyway . . .

Since we’re sticking to the facts in this thread, here’s what I know.

A 2008 paper by Henckes et al link http://www.ncbi.nlm.nih.gov/pubmed/18674877 (sorry, 1-my work comnputer won't let me active link, and 2-it’s in French – thanks Francois for the translation!) identifies two deaths attributed to swimming induced pulmonary edema in divers, at least one of which occurred during a surface swim. These deaths occurred in a series of 19 SIPE cases in 18 patients (one recurrent episode). One death was in a first SIPE occurrence –the other was in the recurrent case, in which the victim recovered from the first episode of pulmonary edema and died from the second.

Francois and I were looking at this a couple of years ago, and he did a search and enumerated a list of 21 media reports of triathlon swim deaths through 2009. I requested autopsy reports on all of them. Ten of the 21 cases either did not have autopsies or occurred in states without open records laws that would not release the reports to me. Of the remaining 11, I was able to get 9 autopsy reports. Six of those had findings consistent with pulmonary edema, such as “pulmonary edema (3 cases)”, “pulmonary congestion”, “foam in airways”, and “fluid removed from respiratory system”. Of that six, official cause of death was drowning in four, hypertensive heart disease in one and atherosclerotic heart disease in one.

I had hoped in 2009 when we were investigating this to have a little more clarity from the autopsy reports, but since in theory pulmonary edema can occur due to negative inspiratory pressure against a closed glottis during drowning, the results were ambiguous enough that I didn’t think it worthwhile to pursue further. I haven’t done any additional follow-up since late 2009. Ingrid Loos Miller (no relation) has an appendix in her book “Fearless Swimming” that enumerates media reports on 25 cases for those who are interested.

That’s the state of the art as I know it today. I think there’d need to be a couple of deaths with known history of SIPE to get meaningful disambiguation on this. And frankly I would rather live with the ambiguity than see any more deaths.

Trey

Trey, thanks for sharing this information with us. The link you provided worked for me. If we include the links above by Dan, there's a lot of useful information here in the thread about SIPE.

If there are details in the article, is there any chance you could get Francois to translate (again) so that you could elaborate the stories of the 2 swimmers/divers who died? How did the problem manifest, what were the rescue details, when did they die, and were there autopsy findings? That sort of thing. In what way(s) were their particular stories similar (or different from) the accounts of triathlon swimmers who have died?

You're obviously very knowledgable about SIPE. I think we'd all be interested in your thoughts....

It appears that SIPE can't be diagnosed until a first episode occurs during an open water swim. It also seems reasonable to hypothesize that SIPE could be a proximal cause of cardiac arrest by progressive hypoxia, if no other mechanism. Yet differentiating the proximal causes of cardiac arrest at autopsy poses the challenges that you list. It might well be the case, like you say, that SIPE simply can't diagnosed definitively after in-water cardiac arrest. So, where does that leave us?

Given our current understanding about SIPE, what specific advice would you have for triathletes? For event directors? For USAT?

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Larry Creswell
http://www.athletesheart.org, @athletesheart

If SIPE is scaring the bejezzus our of you, maybe you should change your name to "chicken little".

I'm with Slowman. Fear mongering panic merchants have no place here on ST. A forum is a place for discussion of facts or opinions, but in all fairness, the opinions need to be based on facts. Rumours waste everyones time and cause waaaaay more grief than they ever should.

If I get one more well meaning email warning me of the next dangerous computer virus or email scam, I swear I'll scream.

Likewise with SIPE hysteria!

next topic please.........

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TriDork

"Happiness is a myth. All you can hope for is to get laid once in a while, drunk once in a while and to eat chocolate every day"

That (the final questions) is a good question. In our original paper, we have identified some of the factors for SIPE. However, aside from hypertension, fish oil,
and a few others, it's difficult to say more because of the small number of cases of SIPE (roughly 31 out 1450, off the top of my head). Multivariate analysis is
even trickier of course. We couldn't conclude for sure that (tight) wetsuits were a trigger, and if I remember well (I don't have the paper with me) the p-value was
on the fence for cold water (Trey will correct me).

The paper linked by Trey suggests that the readiness of the medical team is key to a positive outcome in case of a SIPE event. IF (even some) of the cases of recent
deaths were SIPE related, frankly, I don't see how to get a rapid response with 2500 swimmers in the water, aside from awareness from other swimmers (and of course
this applies to anything...if a swimmer next to you seems in distress, save him/her).

Regarding the two deaths:
1. the first one (row 1 in the paper) died while wearing his diving gear but was at the surface, swimming. No Xrays, no scan. However, the autopsy showed pulmonary
edema.
2. the second one (row 13a and b in the paper) suffered a resp. arrest in his second SIPE event. They don't mention the autopsy, but the Xrays and thoracic scan show
diffusing edema, etc. Thus, a clear case of PE.
There is no more details than that expect that in the second case, it was the diver's second SIPE accident. No details on the rescue either.

As I've said before, we don't have any conclusive evidence that any of the deaths that occurred in tri were SIPE related. However, the evidence points (at least in some
cases) in this direction.

As an aside, part of the paper linked by Trey talks about a more qualitative part of the problem. The authors questioned all the divers about various issues linked to SIPE
and they hint that stress and effort are possibly key factors.

I really don't know what to make of the possibility that SIPE-related symptoms are connected to these deaths. The military literature, which probably represents the best observed cohort data, demonstrates persuasively that SIPE episodes are generally self-limiting. Simple epidemiological inference would suggest that, if SIPE rates really are around 1.5% as we and others have reported, there ought to be a dozen or two SIPE survivors coming out of the water at the big events, and perhaps hundreds of them for every attributable death. So unless there's something about the race environment that makes it more stressful (and deadly) than SEAL training, the observed values don't square with the expected.

The repeat case in the French series I posted this afternoon is extremely compelling and seems very likely to be a SIPE related death. The possibility that a significant fraction of the American triathlon deaths are first-time SIPE episodes seems remote to me.

As for what's to be done, I might conjecture the following. Since we have good evidence that SIPE is mostly self-limiting, getting people in distress completely out of the water and clear of the hydrostatic stress would be a first principle. So getting some surfboards or other platforms out into the water with the kayakers might be worthwhile. Getting people in distress up on the boards might be a better practice than letting them hang on to kayaks to rest while still submerged. Those that deteriorate even if it's from a run of ectopy rather than SIPE would already be loaded and easier to extract from the scene if they crash.

If people with no history really are dying from first-time SIPE epidodes, it can only be because they are staying in the water too long. If aggressive removal from the water reduces mortality, you'd go a long way towards getting your answer. Of course I have no idea how practical this would be, especially in moving-water races where the trouble often seems to be. But that is my first instinct.

I write from Kalmar hospital in Sweden, where yesterday I was an Ironman competitor, and now I am on the ward as a patient, still wearing an oxygen mask, having been diagnosed with SIPE.

I know nothing of speculation about SIPE. I can talk about my experience, if it helps.

The reason I’d like to do that is that I think awareness may help others not to make my mistake.

I am a strong and confident swimmer. This is my 3rd IM long course, and I have many shorter races over an 8 year period. I expected a 1 hr 15 minute swim. In the end it was over 1:40, and it was scary in the last third. At times I was not sure I would make it. I hung off a bridge girder, I sought out shallows to stand up, I approached the safety canoe and clung on to their float to recompose and get my breath. I told them I was shocked at my distress as I am a strong swimmer, and this was a real surprise.

I have never been more glad to climb out of water.

So, I stopped racing right?

No, I climbed on my bike. Confusion and poor decision making seem to be a symptom of sipe and I can attest to that.

I had no power on the bike. I thought it would improve so I pushed on. Kalmar is flat, but there were two or three slopes, not even hills. I struggled really badly on each. But in my head thete was just a resignation that my time would be slow and I might not make cut off, it was clearly ‘my fault, my weakness. ‘

I am 57, male. I was aiming at about 12:30 for the race, for context.

At 70k, 3 hours in, and just about last, I stopped to use a toilet. I discovered I was dizzy and light headed, and coughing, and my hr stayed high even after resting.

I approached the paramedics. At last, a good decision!

They tested my blood oxygen saturation and lungs. Blood was 90%. They put me on oxygen supplementation. It improved, they took me off, it plummeted to 89% immediately. They figured I should stay on the mask. I’m still wearing one now, the next morning. Still coughing, lungs still crackling. Lots of cardio electrodes on.

I’m going to be fine, all the tests are positive. My heart was strained but will be ok.

I was so determined not to DNF I think I took a poor risk and made bad choices by continuing. I can see that now. So if you or others have significant breathing difficulty on a swim when that is not expected, pay attention!!! It may not be sipe at all, but it’s something.

Take care, and don’t mistake ego for determination. Going hard and visiting the hurt locker has to differentiated from continuing when impaired by sipe.

What I am less clear about is how to tell the difference when you are in that position, or more realistically how others, safety marshals might help there.

In my case the gulf between my breathless desperation and my normal swim was massive, and clear enough. It isn’t always so for others.

I hope this helps a useful, fact based, enlightening chat.

And I hope breakfast comes soon..,it’s been a long night.

Glad you made it, and thanks for the info!

Steve M, did you happen to get a new wetsuit just prior to the race, maybe a tighter fitting version? asking since i recall that being a suspected contributor to the issue.
no reason you should've been having a problem as a long time strong swimmer. glad you're ok, and that must've sucked in many ways.

No new, but it’s a good question because it became too small due to covid weight, which I shifted and to me it was a good fit again. But it could be on the tight side is the truth of the matter. I’m going to check that out. Definite maybe.
Status update - day two and much better. The 48 hour recovery duration looks like it will be correct for me. Thank goodness. That was grim.