Elite Swimmers’ Worst Nightmare: Awareness Campaign Warns of ‘Shallow Water Blackout’ Danger

Sunday, February 07, 2016
It’s described as a swimmer’s high — a euphoric mix of pain, confusion, determination and physical exertion that pushes the human body to its absolute limit. And according to those involved in the sport, it’s a common element of competitive swim training.

It’s also potentially fatal.

Inches beneath the surface, swimmers perform dolphin kicks at a furious pace, hoping to shave valuable seconds off the stopwatch. Limbs propel them forward with every movement as their bodies lose oxygen and replace it with carbon dioxide. When competitive swimmers subject their bodies to such punishment in practice, they are preparing for race situations, particularly the final stretch, when they need to leave everything they have in the pool.

Twenty-one-year-old Tate Ramsden presumably was involved in such training on Dec. 26. A junior on Dartmouth College’s swimming and diving team, Ramsden, accompanied by family members, stopped at a YCMA pool in Sarasota, Fla., for a workout. According to an incident report by the Sarasota County Sheriff’s Office, Ramsden attempted what many in the swimming world call a “100” — swimming four 25-meter lengths of a pool without coming up for air — late in his training session. According to police, Ramsden’s family noticed the veteran swimmer unresponsive at the bottom of the pool. Lifeguards on duty performed CPR after Ramsden was removed from the water, but it was too late. By the time police arrived on the scene, attempts to revive Ramsden had proven unsuccessful.

Sarasota County officials say autopsy results won’t be ready for months, but researchers familiar with swimming-related deaths see the telltale signs of “shallow water blackout” — a type of drowning triggered by holding one’s breath under water. Occurring when a swimmer loses consciousness underwater due to a prolonged buildup of carbon dioxide in the body, shallow water blackout, also known as hypoxic blackout, has taken enough swimmers’ lives to prompt watchdog organizations to mount public education campaigns about its dangers.

For competitive swimmers and coaches, the risk of shallow water blackout presents a dilemma.

Underwater swimming is part of competitive swimming, and underwater training is a key component of preparing for competition. Swimmers and their coaches may be tempted to push the limits of underwater training, particularly at advanced levels, but doing so places the swimmers at greater risk of shallow water blackout. More likely, athletes seeking a competitive edge might feel pressured to perform hypoxic — or underwater — drills outside of practice, putting themselves at even greater risk.

In a swimming culture that celebrates the achievements of Olympians Michael Phelps and Ryan Lochte, two famously strong underwater swimmers, training beneath the surface has become even more prevalent, and some say the competitive swimming establishment hasn’t done enough to educate athletes about its dangers.

“I don’t believe (current education) is adequate because we keep having problems,” said Neal Pollock, research director at Divers Alert Network and a senior research associate in anesthesiology at the Duke University Medical Center who has studied the effects of hypoxic training and hypoxic blackout. “We’ve known about this for nearly 60 years. This is not a surprise.”

In 2012, Bob Bowman, Arizona State University’s swimming coach famous for training Phelps, lost 14-year-old Louis Lowenthal when the talented swimmer was found unconscious at the bottom of a Baltimore pool. He was taken to the hospital suffering cardiac arrest and died three days later.

Lowenthal’s death, which the autopsy report determined to be caused by complications of partial drowning, was one of the first incidents of shallow water blackout to attract public attention, given Bowman’s status among Olympic swim coaches. Since then, Bowman has been a vocal advocate for spreading the word about hypoxic training and its dangers.

“Only accomplished swimmers can get themselves in a state where this happens,” Bowman said during a speech to the American Swimming Coaches Association a year after Lowenthal’s death, urging his fellow coaches to be more vigilant. “This doesn’t happen to weak swimmers. This doesn’t happen to recreational swimmers. They can’t work hard enough and drive their CO2 levels down enough to make this happen. The typical victims of shallow water blackout are Navy SEALS, deep divers and elite swimmers.”

In the speech, Bowman noted overhearing several adult, post-graduate swimmers during a training session in Colorado Springs bragging about how far they could go before coming up for air.

“Oh, I can go 75 (meters) underwater,” the first swimmer said.

“Can you go 100?” another responded. “Let’s see if you can go 100.”

Bowman stopped the athletes and shared his experience with Lowenthal and shallow water blackout. “Every one of them thanked me,” he said. “They said, ‘We had no idea.’ ”

“(Swimming coaches) don’t want to change their training methods,” said Tom Griffiths, founder of the Aquatic Safety Research Group at Pennsylvania State University. “Coaches have often told me in my facilities, ‘Don’t tell me how to coach. I don’t tell you how to run your pool.’

“If Bob Bowman can lose one of his swimmers to shallow water blackout, they all can.”

That leaves difficult questions for people involved in the sport: How much and what type of underwater training will prepare swimmers for competition but not place them at risk? Should hypoxic training be taken out of training regimens altogether? How can coaches keep athletes from pursuing extreme hypoxic laps on their own?

The questions are so delicate that some coaches are uncomfortable discussing the topic.

“They are all doing it,” Griffiths said. “And they don’t want to be sued when they kill someone.”

A Competitive Advantage

Swimming underwater is an integral part of racing for a simple reason: It offers a competitive advantage.

“Swimmers travel faster underwater. There’s less friction,” Carter Community Building Association’s aquatics coordinator Glenn McElroy wrote earlier this month in an email to the Valley News. “(Underwater training) has become so prevalent that swimmers are only allowed to swim 15 meters underwater at a time (one starting dive, one turn, etc.) in a race.”

Swimming underwater became so advantageous that the International Swimming Federation, the international governing body for competitive swimming commonly known as FINA, changed the rules to force athletes to perform strokes on the surface in an attempt to even the playing field — first to the breaststroke in 1956, then to the backstroke in 1988, the butterfly in 1998 and, later on, freestyle. Now, athletes are required to come up for air 15 meters after initially entering the water — a measure known as the “15-meter rule.”

Still, coaches and athletes find hypoxic training vital in a sport where control over breathing is critical. It also theoretically increases lung capacity and trains the body to push itself while in situations of oxygen starvation.

“The goal is to get them used to not needing to breathe, to get them less dependent on breathing every stroke,” said Bob Ouellette, chairman of the New Hampshire Interscholastic Athletic Association’s swimming and diving committee and swimming coach at Hollis Brookline High School in Hollis, N.H. “It’s a little bit more difficult than you might think. The whole long, underwater-swim thing, I don’t know many coaches who do that.”

“It’s always been a part of swimming, in general,” said Jack Fabian, former swimming and diving coach at Keene State College and, more recently, resident coach for U.S. Paralympics Swimming. “We’d use it as a type of conditioning. There’s an underwater component of swimming, even more so depending on the stroke. Sixty percent of the race is underwater.

“If you’re an underwater swimmer, you can kick faster underwater than anyone can do a stroke on the surface. … It’s the fastest way to travel.”

Swimmers also might find themselves testing the limits of their underwater endurance, not just at the behest of their coaches but in response to pressure from peers — or from themselves.

Leilani King, a high school graduate from Bellows Free Academy in St. Albans, Vt., who swam several races at the Upper Valley Aquatic Center in Hartford, said she felt the pressure. Either in response to the need to compete against fellow swimmers or a desire to shave time off their results, swimmers too often discount safety concerns, she said.

“For me, I was on a team with kids from 8 to 18 years old,” King said. Now a student at Gannon University in Erie, Pa., she no longer swims competitively. “When a 10-year-old can get the length of the pool and you’re sitting at 15 (meters), you better get a length and a half. It’s kind of expected.”

Underwater swimming was not a regular part of her workouts, King said, but it was used by her coach in another way.

“That was usually our punishment,” King said. “If we weren’t doing what we were supposed to, we’d do laps underwater.”

Swimmers say the sensation is hard to describe — a mix of alerts that beg the body for air along with an adrenaline-laced determination to finish what was started.

“It’s a weird feeling,” said Lyme resident Dave Schafer, the parent of a UVAC swimmer and himself a former competitive swimmer for Florida State University. “It’s painful, but at the same time it’s sort of a rush because you know you’re going to make it to the end. In high school, we were brutal to each other. We used to drag each other down to the bottom of the pool just for fun.”

Blacking Out

Shallow water blackout occurs when an athlete becomes unconscious underwater due to rising carbon dioxide levels.

According to Shallow Water Blackout Prevention, a Georgia-based organization founded by Rhonda Milner, who lost her 25-year-old son to shallow water blackout in 2011, fatalities occur when swimmers with already-lowered carbon dioxide levels — caused by deep breathing that fools the body into thinking it has more oxygen than it actually does, known as hyperventilation — submerge themselves over extended periods of time. As swimmers hold their breath, carbon dioxide replaces oxygen. The abnormally low carbon dioxide levels suppress the body’s normal trigger — to breathe and take in more oxygen — and swimmers lose consciousness. The body subconsciously attempts to breathe, filling the lungs with water.

“When oxygen levels fall to critical levels, blackout is instantaneous and frequently occurs without warning,” according to the website. “Most of the time, underwater swimmers have no clue they are about to be rendered unconscious and that they will be vulnerable to death within minutes.”

Tracking the number of fatalities attributable to shallow water blackout is difficult.

“The frustrating thing is that this is an under-reported, under-appreciated malady,” said Griffiths, who also is vice chairman of Shallow Water Blackout Prevention. “They find water in the lungs, that’s the definition of drowning. … They don’t take into account why he’s in the water or how long he’s been in there.

“For lifeguards, it’s an extremely difficult task,” Griffiths said. “A person doing hypoxic training, chances are good they are a much better athlete than the lifeguard themselves. … Oftentimes, they’ll say (to the lifeguard on duty), ‘Listen, I’m doing some drills. Don’t come and get me.’ ”

Shallow water blackout frequently occurs during extreme training exercises among U.S. Navy SEALS and other military personnel. For deep-sea divers, prolonged underwater training is necessary, and changes in water pressure can make the risk of drowning much higher. But in training, SEALS and some other divers are accompanied by a spotter — someone who pulls them out of the water as soon as they pass out.

That’s hardly the case at pools or lakes. While lifeguards are trained to spot such situations, the response time may be too slow, particularly if a swimmer has chosen a recreational setting for underwater training.

Vermont Gov. Peter Shumlin declared this past June to be Shallow Water Blackout Awareness Month in the Green Mountain State after Benjamin C. “Benjo” Haller, of Underhill, Vt., died of shallow water blackout while spearfishing in the Bahamas. He was 27.

“It’s really important that people wake up to this,” said Rob Sleamaker, founder of Vasa Inc., an Essex Junction, Vt.-based company that sells swim training equipment and who has become an advocate for shallow water blackout prevention nationwide. “Even though it rarely happens, it happens. And it’s completely preventable.

“All it takes is 20 to 30 seconds and you’re done.”

Training Questions

Compounding the challenge for coaches is that no consensus exists in the sport regarding the best approach to underwater training.

“We have been wrestling with hypoxic training drills for decades. We all did it in the past. We do what we have experienced,” Griffiths said. “All coaches and swimmers do it. The problem is extreme, repetitive, competitive breath-holding.

“When novice coaches ask celebrity coaches for their favorite training sets, they most often include extreme hypoxic sets. Plus, our present-day culture encourages extreme sports — deeper, longer, faster survival-type activities. I believe coaches emphasize the benefits of hypoxic training, which have not been proven, and in general don’t mention the risks.”

Some believe the answer is to ban hypoxic training at all levels. Others think the focus should be on education.

Banning hypoxic training wouldn’t stop incidents from occurring, but rather would push it underground, said Pollock, the Divers Alert Network research director.

“There is a significant risk. This is a valid problem,” he said. “That’s why, to me, you have to teach people about core physiology. People generally want to survive. If you teach them and show them why the limits will keep them safe, more often than not, they will show prudence.”

During any normal practice, competitive swimmers in training will perform underwater laps. Jim Wilson, head coach of Dartmouth’s swimming and diving team, said his team does practice hypoxic training — breath holding every five strokes or, at most, 25 meters, the length of a pool.

“We never do four laps (underwater),” said Wilson, who said he was shocked to hear what happened to Ramsden. “We’re very conservative with anything we do in the water. We want to be competitive. … But when we’re training, we never tell or even ask anyone to do something they cannot do. We wouldn’t ask any of them to do anything close to what Tate was trying to do at the end of his workout.”

“Nobody would do (four laps underwater),” said Fabian, the former Keene State coach. “Not for training, ever. … If that were part of a training regimen, for a coach that would not only be frowned upon — you’d get fired on the spot.”

Signe Linville, Colby-Sawyer College’s swimming and diving coach, said pushing hypoxic training on her athletes just isn’t worth the risk.

“I don’t practice it much with my swimmers,” said Linville, now in her second full year with the Chargers. “The most we do is 25 meters underwater. And I specifically explain to them, you need to breathe.”

Dorsi Raynolds, the competitive aquatic director for the Upper Valley Aquatic Center, questioned making a connection between competitive swimming and shallow water blackout. Because making that link would be “dangerous,” she declined to be interviewed for this story. Barbara Hummel, head coach of UVAC’s masters swim team, the UV Rays, and a former competitive swimmer herself, also declined requests for comment.

UVAC holds swimming events for different age groups, including organized competitive swimming and recreational swimming, and hosts practices for Hanover High School’s swimming team. Marauders swimming coach Ann Brechbuhl declined to comment at length for this story, but did say that the mentality toward underwater training among swimmers has changed since the 1970s and that her team doesn’t practice hypoxic training.

Brechbuhl also said she believes that educating the general public, not just lifeguards and coaches, would alert swimmers to the dangers of underwater swimming.

The NHIAA does not regulate underwater training in its Swimming and Diving Policies and Procedures handbook, nor does it mention underwater training or the dangers of shallow water blackout. Ouellette, Hollis Brookline’s swim coach, said the handbook does not tell coaches what to do in practice and that most of its rules and regulations are passed down from the National Federation of State High School Associations.

“It’s like in football,” Ouellette said. “We trust the coaches to run practices in a way that is safe.”

Shallow Water Blackout Prevention recommends one breath for every one length of the pool with significant rest in between hypoxic sets. Griffiths also said his organization recommends “breath control” rather than “breath-holding.”

But Griffiths is afraid that significant change won’t occur until competitors can resist the temptation to test themselves through extreme training.

“There’s got to be a change in mentality,” he said. “There’s got to be a change at all levels: high school, age group and college. Some programs, a typical set they’ll do is 10 individual lengths. If anyone comes up early, they start over. It’s peer pressure. It’s that challenge, that competitive element underwater. … They’ve got to stop doing that.

“People think breath-holding for time or distance is a good thing, like it’s some sort of measure of fitness,” Griffiths added. “It’s an extreme skill. We haven’t been able to break that thought process.”

But Linville and other swimming coaches have little control over what their athletes do on their own. That’s why Linville considers educating her athletes about shallow water blackout and its dangers to be part of her coaching responsibility.

“It leads me to think, like, what are we doing? Why aren’t we coaching and teaching our swimmers about the risk?” she asked.

“My job is not just to make kids faster. It’s to teach them. … I’ve always thought about the life lessons you learn through swimming. … I take it very seriously.”

Josh Weinreb can be reached at jweinreb@vnews.com or at 603-727-3306.

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