Sports Medicine in Open

Water Swimming
Jim Miller, MD
Family Practice and Sports Medicine
Richmond, Virginia

USA Swimming
National Team Physician 1996 – present
Chair Asthma and Diabetes Task Forces
Member IAQ Task Force

FINA
Doping Control Officer
Chair, FINA Medical Congress 2004
 Open Water – the Challenges
• Water – “It’s alive!” • “Things are swimming in
• Water – “It’s too cold!” here!”
• Water – “It’s too hot!” • “Something touched me!”
• Water – “It’s moving!” • “Feeding? What is that?”
• Water – “I cannot see • “What kind of food?”
anything!” • “I cannot see the finish
• Water – “Something is line!”
looking at me!” • “I got sand on me!”
Key Challenge

Flexibility!
 Energy Exchange

• Convection – The transfer of heat from

the movement of air or water across the
body when the temperature of the
water/air is cooler or warmer than the
body.
• Evaporation – the conversion of liquid to
gas, as best demonstrated by sweating.
 Energy Exchange
• Radiation – The heat transfer from
electromagnetic waves either to or from the
body to an object that is not in direct contact
with the body, e.g. sunshine.
• Conduction – The transfer of heat from a
warmer to a cooler object that are in direct
contact.

Note that many of these are often in combination

increasing the impact on the athlete.
 Hypothermia – Mild
(Two Levels of Severity)
99 – 96 F 95 – 91 F

• Shivering and impairment • Shaking, shivering, mild

to perform coordinated impairment of central
tasks nervous system with slow
• Basic treatment: Simple thinking and speech
re-warming by blankets difficulty
(solar) and removal from • Basic Treatment: Same
the exposure (can wrap as prior but will take
in towels and cover with longer to reverse.
sand if removal is not Consider warm shower
practical) and watch closely.
 Hypothermia – Moderate
90 – 86 F
Symptoms Basic Treatment

• Shivering slows down and • Prevention of further heat

stops, with profound loss with basic
slowing of mental maneuvers as prior. No
function. Confusion may aggressive re-warming
include hallucinations and attempts since this results
paradoxical undressing. in shunting cold blood
Muscle rigidity with jerky into the core and may
motions, irregular heart further drop the core
beats. temperature. Evacuate,
where warmed IV’s, etc.
will be considered.
 Hypothermia – Severe
Less than 86 F
Symptoms Basic Treatment

• Coma, falling blood • Time is of the essence

pressure, life and this is a true
threatening cardiac emergency. Evacuate
irregularities. and protect from
further heat loss.
 Hyperthermia – Heat Edema
Symptoms Basic Treatment

• Swelling of hands and • Resolves spontaneously

feet over several days of
acclimatization unless
there are problems with
renal function or there
are medications being
used for underlying
problems.
• See ‘Acclimatization’
 Hyperthermia – Heat Syncope
Symptoms Basic Treatment

• Dizziness to the point • Supine position with

of fainting in the legs elevated, cool
unacclimatized (not iced) liquids and
athlete. This shows resting in a cool
up typically when the place.
athlete stands up • See ‘Acclimatization’
quickly, usually in a
state of dehydration.
 Hyperthermia – Heat Cramps
Symptoms Basic Treatment

• Painful muscle cramps • Rehydration and attention

and spasms to electrolytes, and
massage. If unsuccessful
be attentive to sodium
content in blood as well
as other electrolytes.
• See ‘Acclimatization’
Hyperthermia – Heat Exhaustion
Symptoms
• Fatigue, weakness,
uncoordination, mild
confusion, agitation, headache,
sweating, nausea, vomiting,
diarrhea, muscle pain with
cramping
• Body temp (core) is less than
104 F
Basic Treatment
• See prior recommendations
• Protection from further
exposure
• Spray with lukewarm water in
a setting of cooling fans, cool
oral rehydration.
• Removal to an emergency
facility where advanced
treatment is available and
hyponatremia can also be
ruled out.
 Hyperthermia – Heat Stroke
Symptoms
• Dry – Skin is dry and very
warm with profound confusion,
loss of coordination and other
CNS symptoms including
seizures, coma, hallucinations.
• Wet – Less common with
profuse sweating – otherwise
the same
Basic Treatment
• Medical emergency
necessitating immediate
transfer to an emergency
facility. There gradual central
cooling will be conducted with
attention to potential damage
to cardiac, CNS, renal,
gastrointestinal, hematological,
pulmonary, and
musculoskeletal damage.
 Hyponatremic Collapse
Symptoms Basic Treatment

• Long distance events • Medical emergency that

typically with loss of cannot be evaluated or
central nervous system treated at the site –
function, ranging from transport immediately!
decreased coordination • Water intoxication and
and verbal capacity to acclimatization are
coma frequently at the center
of this medical event,
though other underlying
medical conditions have
to be considered.
 Acclimatization

All athletes vary in their ability to tolerate

cold or heat; thus their duration of
accommodation varies. This can also be
affected by medications or underlying
medical issues.
 Acclimatization
• Layered swim caps (competition rules)
• Ear plugs
• Lanolin and other coating (helps impact but does
not change heat loss)
• Temperature of liquids consumed before and
during the competition/training
• Exposure to high salinity – nausea, vomiting
(electrolytes), swelling of face and tongue
 Sun
• Bad!
• Prevention: Use SPF of 40 or more (debate re:
how much difference there is above 40) applied
every 4 hours with some exception of Bullfrog
and Zinc Oxide (attention to PABA sensitivity)
• Basic Treatment: Avoidance of further injury via
sunscreens and application of lubricants
including 100% Aloe and Lanolin. True sun
poisoning results in needing oral steroids and
will eliminate the athlete from competition.
 Sun Blinding

• Not uncommon due to the intensity of the

sun as well as reflection off of the water
with frequent sighting.
• Symptoms: Tearing and burning
• Avoidance: Mirrored goggles
• Basic Treatment: Liquid tears without
preservatives
 Chafing

Chafing is set up by prolonged exposure to

water, salt, and the variable stroke
patterns caused by wave action.
Variances in stroke inherent with the
athlete can be an underlying risk. It is a
true laceration, prone to infections with all
the complications.
 Chafing
• Common sites: suit lines, • Prevention: Lubricants
shoulder (caused by such as lanolin, Vaseline,
breathing patterns), arm Body Glide, Bag Balm,
pit, inner thighs, back of etc. (Applied by staff,
neck (sighting) not the athlete)
• Basic Treatment: Topical
antibiotics that have anti-
Staph activity and further
protection (avoid
NeoSporin, try Bactroban)
 Critters that Bite and Sting!
Things that Float
Examples: Jelly fish, Portuguese Man-O-War, Sea lice
• Symptoms: Localized pain, • Basic Treatment: Spray with
searing in nature, potentially White Vinegar as soon as
producing a neuropathy, possible. Also may consider
nausea, vomiting, hives, Adolph’s meat tenderizer. Do
localized red spots (Sea lice not rub the site, since this will
are not imbedded!). release more of the contents
of the imbedded darts.
• Sea lice: Lightly apply rubbing
alcohol.
• Severe life threatening allergic
reactions: Epi Pen, which will
result in disqualification of the
athlete.
 Critters that Bite and Sting
Things that Swim
• Consider the expected (sharks, rays, and
turtles) but also anything that is brightly
colored ex. Lion Fish
• Cardinal Rule #1 If it swims up to you, it
is not afraid of you! That is a bad thing!!
• Cardinal Rule #2 If it is brightly colored,
it has no reason to hide! This is also a
bad thing!!
 Critters that Bite and Sting
Things that Swim

………..and one more to worry about………..

 Critters that Bite and Sting
Things that Slither and Crawl
Ex. Sea snakes, venomous shells, octopus (spotted)

• Cardinal Rule #3 – If it is pretty – Do not

pick it up!!
• Cardinal Rule #4 – If it is a shell -
Somebody is probably at home.
• Basic Treatment: All bites from anything in
this category requires emergency
treatment at a medical facility.
 Critters that Bite and Sting
Things that Sit Still
Example: corals
• Symptoms: Burning and stinging with a
localized rash and hives
• Basic Treatment: Like jellyfish stings, the
mechanism of injected barbs is similar,
thus treatment with sprayed white vinegar
and avoidance of rubbing
 Feeding

The topic of feeding during races can raise

medical issues such s what, when, and
how often. There are as many theories as
to the best approach as there are athletes
and coaches but some basic principles
apply to all.
 Feeding
• Rule #1 – The longer the race, the more
frequently the athlete should feed to
sustain ‘fuel in the tank’. Frequencies of
every 15 – 20 minutes are not uncommon.
• Rule #2 – The longer the race, the earlier
the athlete should feed.
• Rule #3 – Plan the feeding what, where
and how, remembering the 3 G’s.
 Feeding

• Grab

• Gulp

• Go
 Feeding
• Rule #4 – Use timed intervals for feeding not
demand intervals. Once the athlete knows that
they need food or water it is too late.
• Rule #5 – The fuel that you consume will not be
available immediately. Thus, plan the sequence
of feedings i.e. carbs early in the race with more
water later. Some athletes prefer their carbs in
gel or solid forms.
 Feeding

• Rule #6 – Practice feeding! The athlete

needs to be accustomed to taking in
nutrition during practice/races as well as
working with feeding techniques with a
feeding extension device. The feeding
station may be a dock or boat (stationary
or moving).
 Feeding
• Rule #7 The athlete selects the flavors and
brings them to the competition.
• Rule #8 The temperature of the fluids is a mirror
image of the environmental temperature.
• Rule #9 Nothing replaces proper hydration and
nutrition prior to the start of the race. If the
fuel tank is low prior to the start you cannot
catch up to your needs during the race.
 Feeding

• Rule #10 - Coaches may not consume the

nutrients until the athlete is finished!
Thank you for your attention!

I would like to thank all of the trainers

and coaches that I have traveled with over
the years. A considerable amount of this
presentation is from all that I have learned
fro them. Every trip has been a give and
take of information that is constantly
changing as open water swimming moves
to the forefront as a new Olympic event.
Go USA!!