The FINA World Aquatics Championship in Budapest was trending on Twitter this week for reasons other than swimming. In dramatic images shared on social media, American coach Andrea Fuentes could be seen diving into the pool to save the life of artistic and synchronized swimmer Anita Alvarez, who blacked out during her routine and sank to the bottom of the pool.
This was the second time in just over a year that the 25-year old had to be saved by one of her team’s coaches after fainting in the water in an Olympic qualifying event in Barcelona last year.
We spoke to Professor Jack Goodman and Assistant Professor Robert Bentley of the University of Toronto Faculty of Kinesiology and Physical Education (KPE) about the incident, how common it is, and how it can be treated and prevented. Goodman specializes in cardiac health and exercise, with a special interest in cardiac response to prolonged exercise, cardiac rehabilitation and exercise and heart failure. Bentley’s area of expertise is cardiovascular physiology, with a special focus on oxygen delivery, cardiovascular control and exercise performance and tolerance.
According to media reports, Alvarez has fainted twice in the water in just over a year. How common is it for high endurance athletes to black out during routines?
Robert Bentley: Blacking out during or immediately after a bout of exercise falls under the umbrella term of exercise-associated collapse. Exercise-associated collapse, while less well-detailed in swimming events, may present in up to two per cent of participants in running events like marathons and ultramarathons.
What could be the possible causes of an athlete blacking out?
RB: Blacking out is typically benign and often arises due to lack of oxygen delivery to the brain. There are several potential causes that often vary depending on environmental conditions at the time of exercise. Common examples may include low blood pressure or low oxygen content in the blood. Low oxygen content in the blood may be particularly relevant with swimming. In most aerobic sports, the breathing rate is unimpeded – allowing your blood to pick up oxygen from the air in your lung at will. Swimming on the other hand, and synchronized swimming specifically, have a very controlled and restricted breathing pattern. This limits the exchange of oxygen because you are not breathing as frequently and fresh air is not being brought into the lung. This can result in low oxygen content in your blood as your brain and active muscles continue to consume oxygen, but the amount of oxygen in your blood is not being replenished as you are not breathing.
Are there more lethal reasons an athlete might black out during exercise or a high performance routine?
Jack Goodman: While rare, lethal cardiac arrhythmias can also cause black outs and when they occur during or immediately after exercise or sporting events, a rare condition known as long QT syndrome is often the culprit. This inheritable condition is identifiable by an ECG read by a cardiologist. In specific subtypes of LQT, exercise rarely is a problem, but some are more risky during exercise and in those cases, cardiac arrest is a risk. Individuals who faint during or immediately after exercise should be evaluated to rule this out. If they show the sign of LQT, family members should also undergo proper ECG evaluation.
Another type of fainting during (any) swim activity is often called ’shallow water drowning’ or black out, which can be induced by hyperventilation before breath holding. Commonly performed to prolong time under water, hyperventilation has the effect of ‘blowing off’ carbon dioxide (CO2) by passing it through the lungs. As CO2 levels are reduced in the blood, the drive to breathe is reduced. The problem is that when CO2 levels plummet as a person is well below the surface and slowly rises to the surface, the combined effect of time, diminishing CO2 and changing pressures tends to lower the ‘drive to breathe’, and the oxygen begins to run out. So, you faint because of a lack of oxygen, yet you don’t have the urge to take a breath.
What is involved in the recovery of athletes in such cases?
RB: While on land, situations of blacking out often require minimal treatment. Commonly, individuals remain breathing and while the individual is lying down, elevating the legs is often sufficient and sometimes supplemental oxygen or intravenous fluids may be administered. However, it’s concerning when someone blacks out in the water because they cannot breathe air. In this situation, administration of life saving interventions can be required after the individual is removed from the water.
How can these occurrences (of losing consciousness) be prevented from happening?
RB: With synchronized swimming, safeguards may be implemented to prevent exposing athletes to a lack of oxygen. While FINA has provided a recommendation against breath holds longer than 40 seconds, throughout a solo routine athletes may spend 60 per cent of their two and a half minute routine with their face submerged below water. Over the course of a routine, an athlete may fight the urge to breathe in order to complete the routine requirements at the expense of a potential catastrophic event.