I wanted to share something about the man who died during the latest Ironman US Championships in New York City, and my personal experience with the same medical condition he suffered from during the race.
After a year of training and focusing my life on this race, I had to pull out around mile 56 of the bike ride. I had developed what I learned was a swimming induced pulmonary edema (SIPE), a form of high output heart failure.
Now, we hear from people involved in the Ironman medical circles that the man who died after the swim likely died from SIPE. Luckily, mine didn't get to that point because I pulled out. But, from what I understand, it doesn’t take much at all to get from where I was to it being fatal. He was a 2.5 hr marathoner and extremely fit. (I note to you there's no way of knowing for sure how he died, but consensus among the medical folks is this is the most likely cause.)
The physiology involves a pooling of the body's blood into the core, and when there is an overload of blood circulation in the core, the weakest link is usually the lung's capillaries so the blood leaks into the lungs. The risk then is of a deprivation of oxygen supply, which at first is just exhausting to the person — and ultimately causes cardiac arrest.
I developed chest congestion and a cough midway through the swim. It onset really rapidly and I even swam to a lifeguard and remember commenting to him about midway through, "I wonder if I developed a chest cold?"
I figured it was just my ingesting too much Hudson River water, although in retrospect I remember noting that it was pink. The coughing became more intense throughout the bike ride, and although I did not note this as a symptom at the time, I observed that I was much more tired than I thought I should be — given how much I had exerted.
I was concerned enough by mile 56 on the bike course that I had the medics call my fiancé Laura who is a pulmonary (lung)/critical care doctor. At that point, I could no longer convince myself that what I was coughing up was just coloring from the Powerade — as it was too obvious that it was just bloody sputum.
Luckily, I had white grips on my handlebars and used that to study the coloring and conclude it was bloody. When Laura arrived, EMS let her take over my medical examination and she immediately knew it was a pulmonary edema. She deemed it too dangerous for me to continue, having seen a patient in her ICU — my age — die of the same thing recently.
So I really dejectedly pulled out of the race. I only pulled over because I was scared, not because I felt like I couldn’t keep going. In fact, I really felt fine enough to keep biking, although I noted that I was more exhausted than I expected to be — relative to the exertion I had expended.
What plagued me the most, the remainder of that day and this past week was knowing that I felt like I could compete, and seeing the physical pain, exhaustion, depletion, that these 2200 athletes endured while I sat antsy and disappointed on the sidelines. I’m sure that most Ironmen do not allow themselves to stop when they feel good enough to power forward, so I think this message is all the more important because this is a crowd of people who are likely to ignore important signs.
I'm sharing this because I think it's really important for triathletes to understand this "high output heart failure," which has an unusual incidence in triathletes — and results from this perfect storm of some or all of the following variables that are independent of your fitness/training.
• Use of Wetsuit: It adds additional extrinsic compression to the extremities that shunts blood up to the core Here, I blame the NY Ironman's poor logistics — as this was further exacerbated by the fact that we had to wear the wetsuit for 2 hours leading up to the swim.
Temperature of Water: It causes blood to pool into the core and out of extremities, to keep the body warm (cold is anything below body temperature, so don't think this only applies in freezing water).
• Pressure of Water: Water exerts a much larger force on bodily tissues than air does, and the increased pressure forces blood from the skin, muscle, fat etc into the vessels/circulatory system.
• Pre-race Adrenalin: It increases cardiac output AND constricts blood vessels moving blood toward the core.
• Hydration: It increases the volume of blood cells
I am not sure what any of us can do with this information given that you can't train to prevent it, but if you are swimming and feel the onset of chest congestion, etc, it should be taken seriously.
It starts with just congestion in your chest and coughing up of what quickly becomes copious amounts of frothy, pink, and occasionally very bloody, sputum, and with that you feel a crackling/rattling deep in your chest when you breathe, and over time shortness of breath disproportionate to the exertion. This is possible in warm water, without a wetsuit, etc, so don't write it off you must stop the exertion at that point, and it will resolve itself (mine did).
The point of this story is awareness. It's too easy in a swim to dismiss a cough as from having swallowed water, or if you're coughing up stuff to mistake its pink color as from a sports drink instead of blood, or to attribute above-average fatigue to the difficulty of the race, etc.
None of the warning signs are debilitating enough to force you to quit, so please just keep this knowledge in the back of your mind, and share it with your friends as well.
Obviously, I don’t know the specifics of the time leading up to the guy's death in this race; but if having this information could have enabled him to identify the warning signs (and given his three little daughters their father back) then there's really no reason for us not to disseminate this knowledge.
It was a hard decision for me to both seek medical attention and then actually agree to quit, and both of those are undoubtedly against the natural instincts of the fierce Ironman attitude. But for obvious reasons I am happy that I made this decision.