Within the months following the Vertical Blue 2023 baggage search of Croatian freediving athletes Vitomir Maricic, Petar Klovar, and Sanda Delija, freedivers took to social media and on-line platforms to debate the performance-enhancing results of the medicine allegedly discovered of their baggage.
Sadly, this can be a largely unexplored subject because of the restricted scientific analysis on freediving.
The aim of this text is to take a deeper look into how medicines get positioned on the World Anti-Doping Company’s (WADA) Prohibited Checklist, perceive the several types of proof in medication, discover medical research associated to every of the substances which have develop into the subject of on-line discussions, present enter from medical professionals on the usage of furosemide in treating freediving-related lung situations, and listen to from Maricic on the substances from the July 4th baggage search.
Freediving Doping Controversy
After 12 months of intensive investigation, together with over 400 hours of analysis and interviews by writer Kristina Zvaritch, DeeperBlue.com is completely releasing this four-part sequence about doping in freediving. The sequence is impressed by the occasions that preceded the 2023 version of the famend Vertical Blue freediving competitors and its aftermath. Kristina acquired no compensation for this investigation.
The sequence contains the next articles:
Whereas this text delves into technical particulars about doping substances and medical proof, you possibly can leap straight to the abstract for a quick, non-technical overview of the findings.
Substances on WADA’s Prohibited Checklist
WADA critiques its Prohibited Checklist yearly, consulting scientific, medical, and anti-doping consultants. This listing undergoes fixed assessment to adapt to new scientific analysis and data from numerous sources.
First, for a substance to be added to WADA’s Prohibited Checklist, it have to be positioned within the Monitoring Program to “detect potential patterns of misuse in sport.” A proposed substance have to be deemed to satisfy two of the next three standards:
- It has the potential to reinforce or improve sports activities efficiency.
- It represents an precise or potential well being danger to the Athlete.
- It violates the spirit of sport (this definition is printed within the WADA Code).
WADA’s Prohibited Checklist is lengthy and in depth, and never each drug listed is inherently dangerous or clearly and visibly performance-enhancing. And whereas the general public usually sees elite freedivers as wholesome people without having for medicine, there are medicines on the listing that each non-competitive freedivers and non-freedivers could also be utilizing, unaware that they’re on WADA’s Prohibited Checklist.
For instance, I take advantage of spironolactone to deal with hormonal pimples – different girls use it to deal with feminine sample hair loss. I used to be shocked to seek out that it’s on WADA’s listing as a diuretic and masking agent. Some girls use Clomifene for fertility, which is listed as an anti-estrogenic substance on the Prohibited Checklist. If somebody takes peptide hormones to heal sooner from an harm – you will see these on the listing. A diabetic freediver who makes use of insulin? Sure, it’s certainly on the Prohibited Checklist as a metabolic modulator.
Since substances on the Prohibited Checklist embrace medicines that individuals must operate in on a regular basis life, WADA created Therapeutic Use Exemptions (TUEs) – waivers granted to athletes that enable them to make use of substances or strategies which can be in any other case prohibited by anti-doping rules attributable to an underlying medical situation.
As acknowledged beforehand, some medicines are mandatory as a result of athletes have bodily or psychological situations that require remedy for respectable therapeutic causes. The last word purpose of the TUE course of is to create an atmosphere the place competitors is fierce but honest and the place an athlete’s well being wants won’t ever cease them from taking part.
Readers ought to word that WADA gives a free Anti-Doping Training and Studying (ADEL) platform with packages concentrating on athletes, coaches, mother and father, medical professionals, and extra. Register and be a part of ADEL to study extra about how WADA protects clear sport.
Alleged Substances Discovered within the Vertical Blue 2023 Baggage Search
On July 4, 2023, a bunch of freediving athletes arrived on Lengthy Island, Bahamas, for the annual Vertical Blue competitors, and William Trubridge, the occasion organizer, intercepted them. These athletes had been advised they wanted to endure a ‘gateway examine’ baggage search and subsequently had their baggage inspected by Trubridge and two armed law enforcement officials. Trubridge wrote down the substances that had been allegedly discovered of their belongings. On the identical time, Croatian athletes Vitomir Maricic and Petar Klovar stayed behind to endure doping management by a Bahamas Anti-Doping Fee doping management officer.
Three days later, Vertical Blue launched an official assertion on its Instagram web page relating to the bags search, which listed each Croatian athletes by title.
The official assertion reads, “Through the search, 4 (4) identified Efficiency Enhancing Medicine (PEDs) had been found within the baggage of each athletes. These included substances which can be on the WADA banned listing for all sport, in addition to different prescribed drugs which can be identified to be PEDs for freediving, and are included on the banned listing for VB in response to its doping coverage.”
The 4 medicines had been as follows:
- Sildenafil – A part of the phosphodiesterase kind 5 (PDE5) inhibitor drug class, sildenafil is primarily used to deal with erectile dysfunction.
- Diazepam and alprazolam – Belonging to the benzodiazepine drug class, they’re used to deal with anxiousness, psychological health-related situations, and seizures.
- Furosemide – Categorised as a part of the loop diuretic drug class, it treats and manages fluid overload situations.
Readers ought to word that of the 4 medicines listed above, just one seems on WADA’s Prohibited Checklist for 2023—furosemide. Nonetheless, furosemide isn’t listed as a performance-enhancing drug; as a substitute, it’s listed within the ‘Diuretics and Masking Brokers’ class.
The remaining belong on the listing supplied in VB Doping Management Coverage and Procedures (a doc distinctive to Vertical Blue that acknowledged that together with WADA’s prohibited listing of drugs, there have been extra prohibited medicine, doable random baggage searches, and extra).
Vertical Blue’s listing contains:
- All substances at present banned by WADA
- Thioamides and different prescribed thyroid suppressants
- Benzodiazepines (e.g. Xanax, Valium)
- Beta-blockers (BBs) and calcium channel blockers (CCBs)
- Any prescription-only substance that enhances efficiency in apnea/freediving and for which the athlete doesn’t have a present prescription.
Why Vertical Blue created its personal extra prohibited listing
I requested Trubridge what his considerations and suspicions had been within the lead-up to Vertical Blue 2023. He advised me, “The considerations and suspicions had been that individuals who had been intending on coming to the occasion and possibly taking performance-enhancing substances. Not solely the performance-enhancing substances which can be on the WADA Checklist and at present banned for freediving, but in addition performance-enhancing medicine by the definition of a prescription pharmaceutical. As an illustration, benzodiazepines had been considered one of these clusters of medicine that aren’t banned for freediving or some other sport. And we began to listen to that on the finish of 2022, others had been speaking overtly about the usage of benzodiazepines.”
“So there was a bunch of freedivers who mentioned, ‘Hold on a minute, that’s a drug with a variety of unwanted side effects.’ So it classifies as a doubtlessly dangerous substance and has a performance-enhancing impact. If that’s the one purpose athletes are taking it, it’s no totally different to taking any of the opposite substances on the listing. It is smart if one thing is anti-anxiety and has been proven to decelerate the center fee would have a performance-enhancing impact on freediving. In order that was one of many substances that we determined wouldn’t be tolerated at Vertical Blue.”
Nonetheless, whereas furosemide is a WADA-banned substance and benzodiazepines had been listed by title within the Vertical Blue Doping Coverage and Procedures, sildenafil was notably absent from the listing.
In an interview, Trubridge confirmed that sildenafil was beneath the class of “any prescription-only substance that enhances efficiency in apnea/freediving.”
“Sildenafil isn’t truly listed within the Vertical Blue Coverage and Procedures,” Trubridge advised me. “However that was one thing that we then (type of in the middle of analysis and really discovering it within the baggage of the Croatians), we then did type of analysis on it. And there have been research that present that in common sport, it doesn’t do something. However in sports activities the place there may be hypoxia, similar to endurance sports activities at altitude and low oxygen, then it does have a profit. And so, it was apparent that there was a possible that this was a PED.”
In different phrases, the investigation into sildenafil’s doable performance-enhancing results in freediving solely started after its alleged discovery within the Croatian athletes’ baggage.
I requested Trubridge, who concluded that sildenafil has potential as a PED, and he knowledgeable me that it was “advisors, most of them medical doctors or analysis scientists.” Amongst these consultants had been Dr. Frank B. Pernett, a Pulmonary Medication specialist and Ph.D. candidate, and Dr. Juan D. Guerrero, a Basic Doctor and aggressive athlete.
Varieties of Proof in Medication
In medication and healthcare, many varieties of proof are used to tell practices, therapies, and decision-making; nonetheless, not all kinds are equal. Beneath, we are going to talk about medical pointers, medical research, skilled medical opinion, anecdotal proof, and the worth of every kind of proof in healthcare.
Scientific pointers
Scientific pointers are carefully-created suggestions that assist medical doctors and sufferers resolve on the very best healthcare for particular medical conditions. They’re created by committees of clinicians practising in a specific subject with educational and medical information. Inside medical pointers are literature critiques of all medical research of particular illness states, assessments and scores of medical research based mostly on the standard of proof, and medical suggestions based mostly on the amount and high quality of proof to help the advice.
An instance of a well-established medical guideline is the American Diabetes Affiliation’s Requirements of Care in Diabetes 2023.
In a really perfect world, we might have medical pointers for freediving medication based mostly on medical research of freedivers, with suggestions within the pointers rated in response to the standard of proof present in a complete literature assessment. The rules would contemplate treating the affected person’s ailment finest whereas avoiding therapies which have demonstrated efficiency enhancement potential in freediving. Suppliers might use the rules’ suggestions and medical expertise to tailor the remedy finest to assist the affected person.
Nonetheless, clinicians immediately are removed from having the ability to make robust suggestions on freediving-related illnesses based mostly on present proof. For instance, see UHMS’ Finest Observe Pointers on the Prevention and Therapy of Decompression Illness and Arterial Fuel Embolism. Their introduction states, “The committee rigorously reviewed proof that was out there. Nonetheless, for lots of the points, there was little or no revealed scientific proof upon which to base suggestions. Due to this fact, proof for the present suggestions relies primarily on skilled opinion (American Coronary heart Affiliation Class II, stage of proof C).”
Scientific research
Scientific research (often known as medical trials or medical analysis) are analysis investigations the place individuals volunteer to check new therapies, interventions, or exams to forestall, detect, deal with, or handle numerous illnesses or situations. An optimum medical research in freediving would come with many contributors who characterize typical aggressive freedivers, and a statistician would assist design the research to get significant outcomes. If doable, the research would use random choice and hold researchers and contributors unaware of who will get the remedy. It will even be useful to make use of a placebo for comparability. These components would supply extra dependable and legitimate outcomes.
When discussing medicine that theoretically improve freediving efficiency, I requested numerous medical professionals and researchers in the event that they knew of any revealed research in regards to the security or performance-enhancing results of the substances talked about on this article for freedivers. None of them might present such research. I additionally looked for these research myself however couldn’t discover any.
Knowledgeable medical opinion
Knowledgeable medical opinion includes the judgment and proposals of extremely skilled healthcare professionals or specialists in a specific medical subject. Nonetheless, skilled opinions a few drug’s performance-enhancing results usually are not a dependable substitute for medical research. A single medical supplier’s skilled medical opinion could lack objectivity or be influenced by private bias (for instance, if a medical supplier actively competes in freediving competitions, they might be naturally biased). It will also be restricted attributable to a slender scope of apply or particular affected person inhabitants. Moreover, a medical supplier’s skilled medical opinion might be outdated if the medical supplier doesn’t sustain with the newest analysis.
Whereas skilled medical opinion can nonetheless be precious, it can not substitute a well-conducted medical research.
Anecdotal proof
Anecdotal proof comes from a number of people’ private experiences. It’s the least dependable and lowest-quality kind of proof in medication. It doesn’t embrace management teams or standardization, and the reporter’s expertise could merely be a matter of likelihood. It’s not peer-reviewed, is closely topic to bias, and doesn’t account for variables similar to different medicines taken, way of life components, and underlying well being situations.
Which means that even when a couple of people report improved efficiency after utilizing a substance, it’s not proof it should work for everybody.
Scientific Research Involving Sildenafil, Benzodiazepines, and Furosemide
NOTE: All medical data on this article has been reviewed for accuracy by a board-certified medical pharmacy specialist intimately acquainted with the ethics of medical analysis.
Sildenafil
Sildenafil was one remedy allegedly present in one of many athletes’ baggage on July 4th at Vertical Blue 2023. Extra generally identified by its model title Viagra, sildenafil is just not banned by WADA. William Trubridge, the occasion organizer of Vertical Blue 2023, confirmed to me that on the VB Doping Management Coverage and Procedures, sildenafil fell beneath the class “any prescription-only substance that enhances efficiency in apnea/freediving and for which the athlete doesn’t have a present prescription.”
Indications
Based on drug data supplied by Merative, Micromedex as revealed in Mayo Clinic, sildenafil is permitted for 2 indications: pulmonary arterial hypertension and erectile dysfunction. Amongst different off-label makes use of, the Wilderness Medical Society Scientific Observe Pointers for the Prevention, Prognosis, and Therapy of Acute Altitude Sickness: 2024 Replace counsel sildenafil could also be thought of as a doable off-label remedy choice to forestall or deal with Excessive Altitude Pulmonary Edema (HAPE), a type of extreme high-altitude respiratory sickness in mountaineers. Nonetheless, this might be the fourth-line choice behind descent, supplemental oxygen administration, and nifedipine. Relying on the reference utilized, sildenafil is assigned both a weak suggestion based mostly on low-quality proof or is just not beneficial.
Sildenafil and train
One research by researchers from the College of British Columbia reviewed 14 revealed research relating to sildenafil and train. The conclusion of the research confirmed that the vasodilatory impact of sildenafil helps cut back pulmonary artery strain (the place deoxygenated blood is transported from the correct coronary heart ventricle to the lungs) throughout exercises and at relaxation. It additionally will increase the cardiac output (i.e., making the center extra environment friendly) throughout train. It reasonably improves blood oxygen saturation (i.e., will increase the oxygen stage within the blood) at excessive altitudes. Nonetheless, researchers acknowledged it didn’t have an effect on efficiency general.
That is additionally true of one other research performed by WADA, which concluded that “sildenafil is unlikely to exert helpful results in oxygen supply or train efficiency at altitudes < 4000 m for the overwhelming majority of the endurance-trained males or girls.”
NOTE: Whereas sildenafil has been proven to enhance blood circulation and oxygen ranges at excessive altitudes, the pharmacist who reviewed the medical research knowledgeable me we can not assume that these advantages apply to a sport that takes place solely underwater the place athletes maintain their breath.
Anecdotal studies relating to sildenafil aiding in restoration
Social media customers allege that sildenafil could have performance-enhancing potential by serving to the athlete get better sooner from depth classes. This, in flip, might assist them progress in depth sooner than an athlete who is just not taking prescription medicines for restoration.
Whereas I wasn’t capable of finding any research learning the usage of sildenafil for this utility, anecdotal data mentioned within the freediving neighborhood means that taking sildenafil earlier than a dive is unsafe and will predispose an athlete to an elevated danger of pulmonary barotrauma (a lung harm attributable to strain adjustments throughout deep dives, also known as a ‘lung squeeze’ by freedivers).
Potential unwanted side effects
A 2013 research confirmed an elevated danger of decompression illness (DCS) in rats when utilizing sildenafil earlier than being “uncovered to compressed air to induce decompression stress and bubble formation.” Researchers initially hypothesized that sildenafil might “have a helpful position on decompression by lowering bubble formation.” Nonetheless, after administering sildenafil to rats and subjecting them to compressed air to induce decompression stress and bubble formation, researchers found that “pre-treatment with sildenafil promotes the onset and severity of neurological DCS. When contemplating the usage of phosphodiesterase-5 blockers within the context of diving, cautious dialogue with a doctor must be beneficial.”
Conclusions
As a result of identified potential dangers based mostly on animal research, it could be unethical to conduct a medical research on sildenafil in relation to diving actions. Due to this fact, any claims about sildenafil being performance-enhancing might by no means be evidence-based, as no researchers would take part in a medical research that might hurt people.
Furthermore, the pharmacist who reviewed these research advised me that the advantages noticed in high-altitude research can’t be assumed to use to freediving, an underwater sport involving breath-holding slightly than steady respiration.
Benzodiazepines
Diazepam and alprazolam, the substances allegedly present in baggage at Vertical Blue 2023, each fall beneath a category of medicines known as benzodiazepines. Benzodiazepines are on Vertical Blue 2023’s listing of prohibited substances – WADA doesn’t at present ban them.
Indications
Based on Australia’s Alcohol and Drug Basis, benzodiazepines are depressant medicine that “decelerate the messages touring between the mind and the physique.” They’re additionally “minor tranquilizers, often prescribed by medical doctors to alleviate stress and anxiousness and to assist individuals sleep.” Based on Mayo Clinic, frequent vacationers can also use them to assist with jet lag and alter to a brand new time zone.
Benzodiazepines are labeled as managed substances attributable to their potential for abuse, misuse, and dependancy potential.
Benzodiazepines in sports activities and archery
Trubridge acknowledged to me that benzodiazepines must be thought of a PED in freediving as a result of they possess anti-anxiety properties, which might be thought to be useful attributable to a lowered coronary heart fee. Nonetheless, research on the impact of benzodiazepines in archery appear to point out the other. Though archery and freediving are essentially totally different sports activities, each require psychological focus, focus, bodily management and precision, and stress and leisure administration – all of which benzodiazepines might be hypothesized to learn.
In an article titled “The position of tranquillizers in sport and train,” the writer concluded that “Tranquilizing medicine don’t seem on the Worldwide Olympic Committee’s listing of banned substances primarily as a result of there isn’t any proof to counsel that they possess direct efficiency enhancing properties.”
The writer goes on to state that “the overall commentary is that the tranquilizing medicine can impair psychomotor efficiency, motor capacity, maximal isometric energy, and maximal energy output each instantly after ingestion and as much as 36 h afterward.”
In one other WADA research titled “Results of Anxiolytics on Superb-Tuning (Neuromuscular) Exercise Efficiency,” researchers investigated rumors that some archers used anxiolytics to decrease anxiousness and cut back physique sway when taking a shot, which might positively have an effect on efficiency. Elite archers got benzodiazepines or a placebo to judge the results of anxiolytics on their efficiency. Researchers concluded that “the outcomes didn’t present any distinction between the teams, neither in bodily efficiency attribute nor in different parameters.”
The conclusion additionally acknowledged that diazepam was given in a single, comparatively low dose of 5mg as a result of “since benzodiazepines trigger sedation and inhibition of motor exercise in greater doses, they’re anticipated to negatively have an effect on motor efficiency in athletic competitions requiring fine-tuning expertise.”
The info additionally confirmed that the resting coronary heart charges of archers who had taken diazepam had been unaffected, and there have been no marked adjustments in coronary heart charges whereas taking pictures.
Threat of dependence
What quite a few research have discovered on benzodiazepines is that they’re extremely addictive and have a excessive potential for abuse, as is mirrored within the 2022 research “Benzodiazepines in sport, an underestimated downside: Suggestions for sports activities medication physicians’ apply,” researchers concluded the research with a nine-point listing of suggestions for sports activities medication physicians “to assist [athletes] in future conditions which entail benzodiazepine prescription, the popularity of dependancy, and intervention methods” since “benzodiazepines are among the many mostly prescribed medicines for insomnia and anxiousness.”
Conclusions
The research above conclude that low doses of benzodiazepines confirmed no marked adjustments in bodily efficiency in archery and that greater doses would go on to have an effect on psychomotor efficiency and different components negatively.
Whereas these results usually are not harmful in archery, they current a critical hazard in deep freediving. Moreover, the potential for dependancy and abuse is one thing to be thought of by prescribing physicians.
I additionally reached out on to WADA to ask if that they had ever thought of including benzodiazepines to the Prohibited Checklist. They advised me {that a} substance should meet two of the next three standards to be thought of for inclusion:
- It has the potential to reinforce or improve sports activities efficiency.
- It represents an precise or potential well being danger to the Athlete.
- It violates the spirit of sport (this definition is printed within the WADA Code).
The WADA consultant went on to state that “at present, there isn’t any indication that benzodiazepines fulfill two of the three standards.”
Furosemide
Furosemide is a prescription drug that’s at present on WADA’s 2023 Prohibited Checklist beneath ‘S5 – Diuretics and Masking Brokers’ class.
Indications
Based on Mayo Clinic, furosemide is a loop diuretic “given to assist deal with fluid retention (edema) and swelling that’s attributable to congestive coronary heart failure, liver illness, kidney illness, or different medical situations.” Mayo Clinic’s web page on pulmonary edema states that “diuretics, similar to furosemide (Lasix), lower the strain attributable to extra fluid within the coronary heart and lungs.”
Diuretics in sports activities
Diuretics are “medicines that enable you to transfer additional fluid and salt out of your physique,” they usually achieve this by making you urinate extra often, as acknowledged by Cleveland Clinic. Close to the usage of diuretics in sports activities, a 2010 research discovered that “though there may be little proof of athletic efficiency enhancement following diuretic administration, their abuse is widespread amongst athletes who wish to drop a few pounds rapidly.”
Whereas this may be useful in wrestling and boxing (the place weight classes exist), dehydration is harmful in freediving attributable to immersion diuresis (the urge to urinate), sweating in a wetsuit, and respiration by the mouth. Based on DailyMed, furosemide is well-documented to trigger vital drops in blood strain and electrolyte imbalances, amongst different opposed results.
Diuretics as a masking agent
On condition that diuretics can be utilized to masks doping brokers by lowering their focus in urine, a 2021 research posed the query, “Can furosemide masks the usage of performance-enhancing medicine?” Researchers concluded that “the masking impact of furosemide is restricted. Furosemide is a doping agent that’s primarily related for sports activities with weight classes.”
This conclusion is additional corroborated by a paper from 2010 titled “The abuse of diuretics as performance-enhancing medicine and masking brokers in sport doping: pharmacology, toxicology and evaluation.” The authors acknowledged, “Within the Nineties, the evaluation of diuretics in doping (by LC-UV or GC/MS) was a problem for anti-doping laboratories because of the heterogeneity of the substances included. For the reason that introduction of sturdy and dependable LC/MS devices their detection in urine samples is not an issue.”
In less complicated phrases, detecting diuretics in urine samples for doping management was troublesome years in the past, however superior know-how has made it a lot simpler to detect immediately. A lot in order that hint portions of six particular diuretics, together with furosemide, which might be current as contaminants in each prescription and over-the-counter medicines, “could also be ample to trigger an Opposed Analytical Discovering in a Pattern collected from an Athlete who took such a product, because of the improved sensitivity of the testing strategies utilized by WADA-accredited laboratories.”
To deal with this difficulty, WADA-accredited laboratories needed to set up minimal reporting ranges for these diuretics (20 ng/mL, a dose that wouldn’t have the ability to masks the presence of one other prohibited substance in a pattern) in order that they wouldn’t set off Opposed Analytical Findings or Atypical Findings in athlete samples.
Conclusions
A research on diuretics in sports activities exhibits little proof of efficiency enhancement in athletes after ingesting diuretics – they’re used primarily by athletes who wish to drop a few pounds rapidly. Diuretics are additionally readily detectable in modern-day doping management.
Furosemide as Pharmacotherapy for Freediving-Induced Pulmonary Syndrome
Freediving lungs at nice depths
Whereas some social media customers steered that the accused athletes seemingly used furosemide as a masking agent for different substances, others talked about that furosemide can be generally used as a remedy for pulmonary edema or pulmonary barotrauma.
In deep freediving, blood shift, pulmonary edema, and pulmonary barotrauma usually are not separate situations however totally different ranges of the identical course of.
Blood shift
When freedivers dive deeper than the purpose their lungs attain residual quantity, blood shifts from the legs and arms to the core, primarily into the lungs, inflicting pulmonary capillaries to develop into very engorged and dilated with blood. On the identical time, air areas expertise unfavorable strain, drawing fluid in—that is known as the ‘blood shift’ and is a pure prevalence of freediving previous residual quantity depth.
Pulmonary edema
Relying on the fluid build-up within the lungs, this may flip into pulmonary edema. Pulmonary edema is outlined because the irregular buildup of fluid within the lung tissue (‘parenchyma’), which is anticipated to a point after very deep dives in freediving. Pulmonary edema might be attributable to cardiogenic (coronary heart) or non-cardiogenic (lung) points – the fluid is similar, however what separates them is the basis trigger.
Pulmonary barotrauma
When there may be an excessive amount of unfavorable strain or an excessive amount of stress on the vessels, blood can leak out of the vessels and into the air areas, leading to pulmonary barotrauma (additionally known as a ‘lung squeeze’ in freediving). Pulmonary barotrauma can vary from delicate to extreme, and the remedy and restoration occasions rely on the severity and any ensuing issues.
Knowledgeable medical opinions
I adopted up with three physicians with expertise in pulmonary and diving medication to get their ideas on furosemide as a pharmacological remedy for pulmonary edema. Moreover, I requested Croatian athlete Vitomir Maricic, one of many athletes whose baggage was searched by Vertical Blue 2023’s occasion organizer, William Trubridge, and armed, off-duty Royal Bahamas law enforcement officials.
All 4 people had been invited to talk at and attend the “Barotrauma and SIPE in Freediving” workshop in San Diego, California, on October 27 – 28, 2023. At this workshop, sponsored by Divers Alert Community (DAN) America and the College of California San Diego Heart for Excellence in Diving, researchers, educators, athletes, and scientists gathered to mix their collective information and coin the time period ‘FIPS,’ which stands for ‘freediving-induced pulmonary syndrome.’
Based on the workshop proceedings, FIPS can embrace “parts of SIPE/IPE [swimming-induced pulmonary edema/immersion pulmonary edema], Barotrauma (ascent or descent), aspiration and different nonetheless unresolved pathophysiological mechanisms.”
Dr. Richard Moon, MD, FACP, FCCP
Dr. Richard Moon, a medical anesthesiologist, pulmonologist, and the Medical Director of the Duke Heart for Hyperbaric Medication & Environmental Physiology, defined that non-cardiogenic pulmonary edema happens in freedivers from excessively elevated pulmonary capillary strain.
For treating pulmonary edema in freedivers, Dr. Moon advised me that “measures embrace administration of oxygen, noninvasive air flow (for instance, CPAP), and in extreme circumstances, endotracheal intubation. As well as, administration of medicine to decrease pulmonary capillary strain could also be used.” He went on to say that “in freedivers, pulmonary capillary strain returns to regular quickly after exiting the water, so in most cases, oxygenation might be maintained whereas the physique resolves the edema by merely administering oxygen with or with out CPAP.”
Dr. Moon concluded by saying that if the above measures usually are not satisfactory, furosemide could also be useful in excessive circumstances to cut back pulmonary capillary strain additional. This data will also be discovered within the shopper model of the MSD Guide on treating Swimming-Induced Pulmonary Edema, authored by Dr. Moon.
Dr. Fernando ‘Bizo’ Silva, MD, MS, DiDMM
Dr. Fernando ‘Bizo’ Silva, an Emergency Medication specialist and diplomate in Diving and Marine Medication specializing in lung ultrasounds and lung accidents, has expertise on the medical workforce in numerous competitions.
He worries about freedivers’ vasomotility (i.e., the power of blood vessels to increase and contract to control blood circulation and keep blood strain within the physique) after a deep dive. Whereas within the emergency room, diuretics are sometimes used to deal with pulmonary edema. Dr. Silva talked about that freedivers who’ve encountered pulmonary edema from a deep dive must be handled in another way since their vasomotility is affected after deep dives attributable to blood shift and the mammalian dive reflex.
“If you come up from a deep dive, your vasculature, or how the arteries squeeze and keep beneath strain, is impaired,” Dr. Silva defined. “And diuretics not solely trigger you to urinate, additionally they affect how arteries squeeze. Which means we could intervene with this course of if we give diuretics inside minutes after a deep dive, which might lead to adjustments within the vasomotility similar to dangerously low blood strain or a scarcity of responsiveness of the arteries squeezing. That’s why I say that giving diuretics and different medicines that have an effect on vasomotility is doubtlessly very catastrophically harmful for freedivers – no less than till I’ve extra data.”
Dr. Igor Barkovic, MD, Ph.D., Assistant Professor
Dr. Igor Barkovic is a pulmonologist and significant care specialist who heads the Centre for Analysis and Training in Undersea, Hyperbaric, and Maritime Medication in Rijeka, Croatia. He has spoken at numerous conferences and authored a number of scientific analysis papers on breath-hold diving.
He’s additionally the doctor who prescribed Vitomir Maricic and Petar Klovar furosemide to be used in particularly distant places in excessive emergency conditions in this letter.
Dr. Barkovic knowledgeable me that pulmonary edema in deep freediving outcomes from the gorge of blood that involves the thorax and enters pulmonary circulation. He sees this as parallel to cardiogenic pulmonary edema, the place the primary line of remedy is diuretics as a result of the center has much less work to do eradicating the blood from pulmonary circulation.
“Drawing parallels is probably the most you are able to do if there are not any outcomes, so we made a parallel to cardiogenic edema,” Dr. Barkovic advised me. “Vitomir and Petar go to distant islands in Croatia and everywhere in the world and ask me what they need to do – I advised them that they want oxygen, supplied them with a CPAP machine, and prescribed them furosemide. How do I show the three collectively will work? There’s no proof – nobody has completed it, but it surely’s logical to me because it’s much like cardiogenic edema.”
“I advised them to not use it beforehand as a result of it’s not useful and doesn’t improve outcomes – it might probably even be harmful to make use of it earlier than diving. However it’s about severity. After FIPS – and provided that they’ve such issues that they should go to the emergency room and there may be none – then they’ll apply it to themselves. I requested my colleagues round Croatia about what they might do. 100% of the cardiologists and pulmonologists advised me in the event that they noticed pulmonary edema, they might give diuretics (for instance, furosemide).”
Dr. Barkovic touched on an fascinating level. “This can be a actually slender a part of medication, and nobody on this planet is an skilled or is aware of the whole lot about it as a result of there may be little or no identified in regards to the subject,” he advised me. “I’d prefer to stress that somebody who’s towards it might probably have their very own opinion, however they can’t be certain whether it is good or not good as a result of there isn’t any proof. It’s exhausting to be an skilled at one thing that people know little or no about – I don’t assume that there are greater than 10 – 20 individuals round that may carry out such outcomes as Vitomir and Petar. So we’re all talking about one thing we don’t know a lot about.”
Vitomir Maricic weighs in
Vitomir Maricic, one of many Croatian freediving athletes whose baggage was searched within the weeks main as much as Vertical Blue 2023, is a pulmonary rehabilitator who actively participates in a number of analysis initiatives regarding security in deep freediving within the Centre for Analysis and Training in Undersea, Hyperbaric and Maritime Medication in Rijeka, Croatia. He additionally helped design the ‘Lung Squeeze Survey’ sponsored by Divers Alert Community (DAN) and the College of California San Diego (UCSD).
Maricic’s views on furosemide
Maricic maintains that furosemide is an emergency remedy medication for pulmonary edema. “Petar Klovar and I by no means truly wanted to make use of it, and I consider the overwhelming majority of circumstances in freediving might be managed with out it. Utilizing it additionally means you possibly can take a look at constructive for it, so you might be instantly out of any competitors till you clarify why you used it and get a TUE. In our case, since we’re a part of ADAMS, we’d must exclude ourselves from the whole lot since we will get examined at any time and anywhere after which fail doping management. So it’s not an choice except it’s actually a life-saving factor.”
ADAMS stands for Anti-Doping Administration and Administration System, a vital device utilized by WADA and anti-doping organizations to make sure efficient monitoring and implementation of anti-doping rules. Maricic has been a part of ADAMS since 2018, whereas Klovar joined in 2021. They estimate that in 2023 alone, Maricic had 6 to eight in- and out-of-competition exams, and Klovar had 12 or extra. Moreover, Maricic acknowledged to me that neither had examined constructive nor missed a single management.
“A diuretic would additionally depart you dehydrated, and possibly you wouldn’t have the ability to come near any good outcomes anyway, so in any case, utilizing it means many issues for an athlete,” Maricic continued. “I solely as soon as noticed a freediving sufferer the place I want I had furosemide close by because it was very exhausting to maintain their saturation above 80%, even with the assistance of oxygen. It was fortunate we had sufficient oxygen in that case. Although I might use this solely in extraordinarily extreme circumstances, it could be no shock that it could be one thing you get in a hospital, even for a really mild squeeze, and we see it occurring on a regular basis.”
Furosemide and retroactive TUEs
Maricic additionally shared his interpretation of Article 2.6 of the WADA Code. In his opinion, a TUE isn’t mandatory for furosemide if it’s meant for life-threatening emergencies slightly than remedy. He’s referring to a remark within the Code relating to Articles 2.6.1 and a pair of.6.2, which states, “Acceptable justification could embrace, for instance, [a] an Athlete or a workforce physician carrying Prohibited Substances or Prohibited Strategies for coping with acute and emergency conditions [e.g., an epinephrine auto-injector].”
Moreover, Article 4.1 of WADA’s Worldwide Requirements for Therapeutic Use Exemptions permits athletes to use for a retroactive TUE (“a TUE for a prohibited substance or prohibited technique after utilizing or possessing the substance or technique in query”) if a prohibited substance is used or of their possession for emergency remedy.
“All prescribed medicines include official paperwork issued with them; furosemide is a type of, identical to benzodiazepines or some other medicines you want a prescription for,” he advised me. “I personally advised this to William Trubridge on a number of events after he himself requested if we had the documentation for the medicines we carried. I answered ‘sure’ in entrance of everybody there, however he by no means bothered to ask us once more or examine something. In actual fact, it appeared he didn’t actually wish to hear this and hoped we might say no. Later, it grew to become clear to me that for his plan, it was irrelevant. The purpose was to get us in hassle, to not examine or to combat doping.”
Conclusions
It’s clear that the subject of how you can deal with FIPS continues to be majorly unexplored, and physicians of various specialties and backgrounds differ of their approaches to managing the situation relating to freediving. A number of contributors of the “Barotrauma and SIPE in Freediving” workshop acknowledged that discussions left them with extra questions than solutions. Nonetheless, there may be hope that this workshop is step one and that extra analysis will observe to grasp FIPS higher and supply steerage in its administration.
Vertical Blue’s Location
It is very important word that Vertical Blue takes place in Dean’s Blue Gap in Lengthy Island, Bahamas. At this distant location, a deadly accident occurred through the 2013 version of the competitors. Nicholas Mevoli was pronounced lifeless on the Deadman’s Cay Clinic on Lengthy Island following his no-fins dive to 72m (236ft). Autopsies attributed his explanation for demise to “pulmonary hemorrhage attributable to barotrauma.”
Moreover, an athlete who participated in Vertical Blue in recent times suffered a extreme case of FIPS. Based on a report from Vertical Blue’s Chief Medic, the island is quoted to have “very poor medical provision. There isn’t a hospital, and solely a clinic. There’s one doctor for the entire island. They aren’t accustomed with managing very sick sufferers.”
It went on to state that getting an X-ray or CT scan on Lengthy Island is unattainable. Due to this fact, in a really critical medical emergency, it seems that the one strategy to get the mandatory medical care can be to get airlifted to both Nassau, Grand Bahama, or america, doubtlessly taking hours to succeed in a hospital geared up for such an emergency.
Vitomir Maricic on the Alleged Substances
I had questions in regards to the substances allegedly discovered within the Croatian athletes’ baggage. After I contacted Vitomir Maricic in December 2023, he knowledgeable me that his lawyer suggested him to not communicate publicly. In September 2024, I once more contacted him and requested him the next questions, and I revealed his solutions as he advised me.
I additionally tried Petar Klovar, who declined to remark, stating, “The explanation I don’t really feel inclined to remark is as a result of feelings and ego are what created this scandal/scenario within the first place. My feedback and opinions usually are not of nice use as a result of they’re subjective. My solely curiosity is for info to lastly come out so individuals can realistically look upon this example and create their very own opinions.”
Have you ever ever used performance-enhancing medicine?
“No, not solely have we by no means used them, we strongly advocated towards it with the athletes which have confessed to us to utilizing them. After all, we’re speaking about doubtlessly performance-enhancing medicine, not the precise performance-enhancing medicine which can be banned – we might discontinue any type of work or collaboration with them.”
“I personally had a foul expertise after I began freediving, teaching a man who was utilizing precise performance-enhancing medicine whereas he was swimming (in his swimming profession earlier than he began freediving). After, he failed a doping management in freediving. After all, with out understanding any of this, this expertise was one of many worst teaching experiences in my profession. The frustration that I had after on this athlete – I undoubtedly be sure that to at all times ask individuals and to make it clear that I must know the whole lot they’re taking. In case it’s one thing that’s truly performance-enhancing and banned, then we’re not working collectively, and that’s it.”
“In my view, there’s a purpose why these medicine [benzodiazepines and sildenafil] usually are not listed as performance-enhancing – as a result of they aren’t. And the athletes who experiment with them have extra of a placebo impact, being unaware that any drug can alter our pure homeostasis, which for my part, isn’t good in sports activities, as it might probably have unfavorable unwanted side effects.”
“Anybody who has spent a while coaching with us is aware of that we depend on a lifetime of sport, fashionable coaching rules, and a constructive mindset with a playful and experimental method to competing.”
Did your workforce have furosemide, benzodiazepines, and sildenafil in your baggage on July 4, 2023?
“Sure, a few of the substances we did certainly carry with us, as beneficial by our medical workforce.”
Why did you could have these substances in your baggage?
“We are able to’t actually put all substances beneath a typical denominator – sildenafil has a really identified utilization. Benzodiazepines as properly might be helpful with many neurological and muscle-related points, in addition to serving to restore a circadian rhythm, which is vital to athletes usually touring between continents. Diuretics could be a life-saving measure in circumstances that may happen in freediving, and having these medicine with you in places like distant Caribbean islands the place no hospital or correct pharmacy is offered. All this stuff are very simple to examine to anybody with a important thoughts and the reasoning to grasp proper from incorrect sources.”
“None of those medicine is in any manner efficiency enhancing, in actual fact, it’s detrimental to freediving efficiency and might be harmful, which can be very clear to anybody who truly needs to consider it.”
Do you could have prescriptions for these medicines?
“Sure, after all, for something we supply throughout borders, if wanted, we’ve all the correct medical documentation to legally have it with us. With having these medicines, we by no means had any benefit over any competitor, nor have we used them or would advocate them for use for freediving efficiency. Even the WADA Code has an additional part on possession, which offers particularly with substances like furosemide.”
Upon request, Maricic supplied me with the documentation of all of the prescriptions apart from sildenafil.
Have you ever ever taken furosemide?
“Now we have by no means truly taken furosemide or some other diuretic. Fortunately, we by no means had such an emergency that we would want it. Furosemide is taken in particular circumstances of lung squeezes the place different technique of restoration usually are not doable. Taking it exterior of a life-threatening state of affairs can be absurd. Firstly, it is rather detrimental to any type of sports activities efficiency, and secondly, we would want to step out of any competitors circuit as a result of, since we will get examined each day, we might additionally fail a management in case we take furosemide any minute.”
“After all, we might ultimately get a TUE on this case, however you possibly can’t get a TUE in 5 minutes and we will get examined anytime, anyplace, since we’re in probably the most strict WADA ADAMS class. So, taking this anyplace can put us liable to failing a management. Hiding a substance with furosemide is unnecessary for precisely the identical purpose. A very long time in the past, when these substances weren’t so simply detectable, this was extra generally used – now, its solely function is in weight-category sports activities, the place excessive dehydration from a diuretic can drop your weight class, aside from the precise medical use, which is, amongst different issues, particularly used for lung edema.”
“That is additionally simple to examine, and plenty of freedivers have this expertise themselves, as they get furosemide when they’re ‘evacuated’ to a hospital for lung squeeze. That is completed ‘simply in case’ and as a part of commonplace process, since hospitals usually are not too acquainted with lung squeezes, so that they do it to guard themselves in a manner. In actuality, 99.9% of those diving-related traumas are handled with out diuretics. However there are circumstances the place that is mandatory.”
Transient Abstract
For a substance to be proposed for addition to WADA’s Monitoring Program after which subsequently the Prohibited Checklist, it should fulfill two out of the three standards: it has the potential to reinforce sports activities efficiency, it represents an precise or potential well being danger, or it violates the spirit of the game. Nonetheless, some medicines are mandatory for individuals to operate in on a regular basis life, so WADA created Therapeutic Use Exemptions (TUEs).
In medication, several types of proof are used to tell practices. Scientific pointers include literature critiques of medical research and are rated based mostly on the extent of proof and high quality. Within the absence of medical research, skilled medical opinion is just not thought of an equal substitute. Moreover, anecdotal proof is taken into account the least dependable and lowest-quality kind of proof in medication.
When wanting intently at medical research on sildenafil, most study performance-enhancing advantages at greater altitudes however conclude there are not any such advantages at decrease altitudes. The pharmacist who reviewed the medical research I included advised me it’s vital to notice that the altitude-related advantages of sildenafil in constantly respiration contributors can’t be assumed to use to underwater breath-holding sports activities.
Moreover, a regarding medical research confirmed that administering sildenafil to rats and exposing them to decompression “promotes the onset and severity of neurological DCS,” making it unethical for researchers to carry out related medical research on people sooner or later.
Relating to benzodiazepines, research I discovered confirmed low doses of benzodiazepines given to medical research contributors confirmed no marked adjustments in bodily efficiency. In distinction, greater doses would negatively have an effect on psychomotor efficiency and different components. These opposed results would current a major hazard for freedivers at depth. Moreover, there’s a excessive potential for dependancy to benzodiazepines, which is an important issue physicians should contemplate earlier than prescribing them.
As for furosemide, diuretics assist take away additional fluid and salt from the physique by growing urine manufacturing. This could heighten the chance of dehydration, which is particularly harmful for freediving performances. A 2010 research discovered little proof of athletic efficiency enhancement from diuretics, although their abuse is widespread amongst athletes in search of speedy weight reduction for sports activities with weight classes. Diuretics have been administered to sufferers in emergency departments presenting with signs of pulmonary edema. Whereas they may have been used prior to now to masks doping brokers, modern-day doping management simply detects their presence in urine.
Furosemide stays a typical pharmacological remedy given to sufferers experiencing pulmonary edema within the emergency room; nonetheless, its use for freediving-related accidents is just not as clear. Three physicians had differing opinions on utilizing it to deal with freediving-related pulmonary edema and pulmonary barotrauma, and remedy in medication usually varies between physicians attributable to totally different backgrounds and experiences.
After he was requested about furosemide, aggressive freediving athlete Vitomir Maricic acknowledged that he and fellow athlete Petar Klovar have by no means had to make use of it and that the overwhelming majority of circumstances in freediving don’t want it. He talked about that it’s additionally not an choice for them to make use of except they want it since they get examined out-of-competition usually all year long. Based on the WADA Code, substances wanted to deal with acute emergencies might be justified. Maricic maintains that when he advised William Trubridge (Vertical Blue’s occasion organizer and fellow athlete who searched Maricic’s and Klovar’s baggage) that he and Klovar had documentation for all medicines they had been carrying, Trubridge didn’t observe up on the declare.
Vertical Blue stays a distant location, unequipped to deal with critical medical emergencies. US freediver Nicholas Mevoli died in a tragic accident at Vertical Blue 2013 attributable to “pulmonary hemorrhage attributable to barotrauma.” Based on a report from Vertical Blue’s Chief Medic, the island is quoted as having poor medical provision, no hospital, and solely a clinic, and it isn’t used to treating very sick sufferers. In life-threatening conditions, sufferers requiring pressing medical care on Lengthy Island have to be airlifted to Nassau, Grand Bahama, or america. This journey might doubtlessly take hours.
I requested Maricic in regards to the workforce’s use of PEDS, to which he acknowledged they’ve by no means used them and advocated towards them. As for the substances being of their baggage, he confirmed that they had been and acknowledged their medical makes use of and the truth that that they had prescriptions for them, which I confirmed. Maricic additionally acknowledged his workforce has by no means needed to take furosemide and that they haven’t but had an emergency scenario the place it was wanted.
Remaining Ideas
This in-depth take a look at the substances allegedly present in athlete baggage at Vertical Blue 2023 highlights the shortage of clear, evidence-based steerage relating to medicines and freediving efficiency. It additionally emphasizes that not all varieties of proof are equal, so you will need to contemplate the supply and, at occasions, conduct your analysis when given new data, notably relating to doubtlessly performance-enhancing medicines in freediving.
Nonetheless, some important questions stay:
- How can insurance policies and procedures be adjusted to remove grey areas that athletes may exploit whereas defending their rights and medical privateness?
- Ought to athletes be required to open up to the general public the medicines they’re taking and the medical causes for taking them within the occasion they’re accused of doping?
- Given the shortage of medical research particular to freediving, how ought to freediving organizations stability the usage of medicines for respectable medical functions towards considerations about potential efficiency enhancement?
- When freediving organizations or competitors organizers add substances to their prohibited listing not but included in WADA’s Prohibited Checklist, how can they guarantee their testing procedures align with WADA’s pattern assortment and evaluation protocols?
As aggressive freediving continues to evolve, standardized, well-researched insurance policies are desperately wanted. If freediving goals to develop into a part of the Olympics, funded medical research and the creation of medical pointers will help guarantee honest competitors and athlete security, particularly within the public eye.
The ultimate article of this sequence will additional discover the VB2023 baggage search and doping management and purpose to deal with unanswered questions surrounding these occasions.
