- Email: [email protected]
Professional Cycling Taps Emergency Physicians as Team Physicians
Professional Cycling Taps Emergency Physicians as Team Physicians by ERIC BERGER Special Contributor to Annals News & Perspective
I
t was near the end of a 123-mile stage in northern Italy when Christian Vande Velde crashed while riding his racing bike at 40 miles/hour. The star cyclist had finished fourth in the previous year’s Tour de France, and now the Chicago native had lined up to race the second most famous grand tour, the Giro d’Italia, in May 2009. Instead of battling for the leader’s jersey, however, he lay in the middle of an Italian road, his dreams dashed. Among those first on the scene was Prentice Steffen, MD, the chief physician of Vande Velde’s racing team, known as Garmin-Slipstream at the time. “Christian was involved in a very bad crash,” Dr. Steffen, an emergency physician, recalled in an interview. Later test results showed the rider had sustained fractures, including 3 vertebrae, his pelvis, and 2 ribs. But cyclists are used to enduring great pain, and with Dr. Steffen by his side, Vande Velde’s condition was stabilized and he received treatment in a hospital before returning to his home in Girona, Spain. Less than 2 months Volume 68, no. 3 : September 2016
later, he recovered enough to ride in the Tour de France, finishing seventh. Team physicians have had a checkered role in the history of the sport of cycling, as Dr. Steffen knows all too well. More than a decade before jumping out of a team car to attend to Vande Velde, Dr. Steffen had been a physician for the US Postal cycling team, for which Lance Armstrong would later ride and win 7 Tours de France (and subsequently be stripped of them for doping). After he raised questions about team doping in 1996, Dr. Steffen’s contract was not renewed, and he was replaced by “physicians” who prescribed drugs such as EPO in subsequent years. But now on the Italian roadside, working for the Slipstream team, Dr. Steffen had found gainful employment again for a cycling organization that actually wanted real physicians in the team car and in the hotels at night, looking after riders. His work as an emergency physician, one of the first in cycling, has led to 2 others joining the team to care for riders during a cycling season that lasts from January through October. “As emergency physicians, we are trained to be problem solvers,” Dr. Steffen said. “Whatever the problem
is, we need to know how to solve it. Almost anything can happen to the human body during a race, and we’ve got to be able to take care of it, or get the care started and find someone who can take care of it. Our profession is accustomed to working out of chaotic environments, and here we might be giving care with a hand out of a car rolling along, in the back of the bus, or in a hotel room. But never in a hospital.” Growing up in Oklahoma, Dr. Steffen always was involved with sports, running track and field and cycling avidly during his college years. Later, in medical school, his orthopedic surgery attending physician was Ted Percy, MD, who had been the chief medical officer for the Canadian team at the Montreal Olympics in 1976. He helped get Dr. Steffen a position at the 1986 Road Worlds Cycling Championships in Colorado Springs, CO. Later, while he was a medical resident from 1987 to 1990, Dr. Steffen worked several races, including the Tour DuPont and, yes, the Tour de Trump, named after the businessman and presidential candidate. By 1993, Dr. Steffen began working as a team physician, first for Subaru-Montgomery and then its successor US Postal, the team that Lance Armstrong would join in 1998. One of the defining moments of Dr. Steffen’s career occurred in 1996, at the Tour of Switzerland. Two of the US Postal riders, Tyler Hamilton and Marty Jemison, approached him and asked for information about administering performance-boosting drugs. The physician reported the incident to the team’s director, Mark Gorski. Annals of Emergency Medicine 17A
Dr. Steffen’s contract was not renewed at the end of the season, and the team hired the “Spanish guys” who, much later, were implicated in doping scandals. That was the end of it until 2001, when Dr. Steffen publicly recalled this story to David Walsh, a well-known Irish cycling journalist. Walsh’s subsequent story implied that Armstrong was part of a cycling team that condoned doping, and the Tour de France winner vowed to make Dr. Steffen’s life miserable. Armstrong got his chance 5 years later, after Dr. Steffen had linked up with a former cyclist, Jonathan Vaughters. Although Vaughters had experienced some success on the bike, he’d had to use drugs when he rode alongside Armstrong and others in the late 1990s. After that miserable experience, he’d started a “clean” team devoted to encouraging riders to race without taking illegal drugs, and the amateur team was then sponsored by TIAA-CREF. (It later would become the professional GarminSlipstream team that Vande Velde rode for.) Dr. Steffen served as the team’s primary physician. Shortly after Armstrong retired from cycling for the first time in 2005, the French sports newspaper L’Équipe reported on a research project that had retested 6 urine samples taken from the cyclist during the 1999 Tour de France. The samples were found to be positive for EPO. After that report, Dr. Steffen gave an interview to the French newspaper and was asked whether there was a certain type of rider who doped. “Unpleasant people like Lance Armstrong dope and nice people like Tyler Hamilton also dope,” Dr. Steffen said. At this time, Armstrong was essentially the godfather of US cycling, with influence over the sport’s ruling bodies and race directors in the United States. He 18A Annals of Emergency Medicine
telephoned Vaughters and demanded Dr. Steffen’s resignation. He got it. “That was a really dark moment in my experience with Lance Incorporated,” Dr. Steffen recalled. “We were just a budding team at the time, and Lance had some sway with some of our sponsors. He threatened to destroy the team. After a series of conversations, it was decided that the resignation had to happen, and Lance’s team wrote the apology I gave. JV [Vaughters] said as soon as this dies down, we’ll bring you back in.” Dr. Steffen returned to the team the next year. For team physicians at races, the days are long. On a typical day, they wake up early in the morning with the mechanics, who prepare the bikes for the type of terrain for that day’s racing, and the soigneurs, who provide massages for the riders, run errands, make sure the riders are fed during the race, etc. The physician will check on the riders during breakfast and make rounds before the bus leaves the hotel. After this transfer to the start line, the physician spends 4 to 6 hours in the team car. “Then, most days, nothing happens, and everybody’s happy when the team doctor has nothing to do,” Dr. Steffen said. After the day’s racing, the physician will contact the riders in the evening before dinner and bedtime. Hotels are assigned by the race organizers, and during a 3-week grand tour, that can sometimes mean 21 to 23 different beds in as many nights. It’s the whole spectrum, from amazing chateaus to “total crap hotels in a sketchy area of town.” The Tour de France organizers have a system by which they rank each hotel on its quality and, during the course of 23 days, try to even it out so that each participating team has roughly the same experience. “That makes us laugh because we know that when we’re in a really great
hotel that in a few days we’re going to be in a really shitty hotel,” Dr. Steffen explained. The team’s experience with Dr. Steffen has led to the hiring of other emergency physicians to care for riders. Of the team’s 4 physicians, each of whom rotates in and out for different races, 3 are now emergency physicians. The practice is suited to cycling not only because of the diversity of training but also because of the flexible shift work that emergency physicians do. Phil Stawski, MD, had worked in Lassen Volcanic National Park in California before meeting Dr. Steffen and joining the cycling team back in 2012. He started his tenure with a bang, serving as the team’s physician during the second half of the Giro d’Italia in 2012, which was won by the Garmin cyclist Ryder Hesjedal, a major breakthrough because it was the team’s first (and only) grand tour victory. The care delivered during the course of a cycling season covers much of medicine’s broad spectrum, Dr. Stawski said. In the spring, when some of the major 1-day “classics” are held on the hills and cobblestones across Belgium and France, allergies pose a major threat. During 1- and 3week races, the confined spaces of hotels and team buses, with 9 riders and 15 to 20 staffers, means that any gastrointestinal or upper respiratory bug can easily wipe out a team’s race chances. On the roads themselves, the most common injuries are lacerations and bruises from light crashes and breakages such as collar bones. Then there are the more rare but more serious cases of traumatic injury and cardiac arrest. “It’s everything you see in an emergency department but on a road, and in some very unique situations,” Dr. Stawski said. Quick calls must be Volume 68, no. 3 : September 2016
made: will tests in a local medical center be sufficient, or must a rider quit and travel hours away to a major hospital? Issues such as socialized medicine complicate the picture further. A physician must know what clinical options are available as the race moves across Europe, the Middle East, and other places. The team’s other board-certified emergency physician, Kevin Sprouse, DO, agreed with that assessment. Similar decisions must be made off the bike, too. “A lot of the medicine on these trips happens between stages, maybe with a late-night knock on the door when a rider has some belly pain,” he said. “We’ve got to decide whether this is a really serious thing, or maybe.just gut rot from too many energy gels.” Again, having a background in emergency medicine offers the perfect kind of preparation for these various tasks. In 2014, the Giro started outside of Italy, in Belfast, Ireland, with a team time trial. This is when the entire team rides together to get the quickest possible time around a course, with the team’s time based on the time of the fifth rider. Dr. Sprouse was the physician that day, and the entire team crashed, with broken clavicles and other injuries. It was Dr. Sprouse’s job to assess damages and to get riders healthy enough to ride because the clock was ticking for the entire team.
Volume 68, no. 3 : September 2016
“It was almost like a mass casualty scene, and as an ER doc we’ve all had those days when they roll in 5 or 6 ambulances at a time,” he said. “Being comfortable with that situation made it so that when I jumped out of the car I didn’t lose my head. It’s a little bit harder because you’ve got relationships with all of these guys, it’s almost like your friends are lying there, and you’ve got some competitive pressure. But I felt as prepared as I could possibly be for such a situation.” With the younger people coming through to serve as physicians now, Dr. Steffen said he’s planning to retire at the end of this cycling season. He’s been traveling to races around the world now for 24 years, and he will turn 56 in November. Dr. Steffen has tired of the long plane trips. He’ll have more time to work at the Dominican Hospital in Santa Cruz, CA, where he now spends half of his time. And Dr. Steffen can leave the sport feeling pretty good about things. Cycling is far from perfect. Cheating still occurs, but it seems far less prevalent. It continues to trouble Dr. Steffen how some team “physicians” use drugs that could harm young men to improve their performance. “It was really just unacceptable what was going on,” he said. “I suppose you can find people to do whatever you want them to do. But as
a physician, that was really hard to take.” With Vaughters, he’s had the opportunity to work for someone who valued clean riding, so Dr. Steffen could put medicine and rider health first and push ideas such as a noneedle policy, in which athletes cannot compete for several days after an injection. After all of the Armstrong mania, from his stunning rise to fall from grace and doping admissions, Dr. Steffen says he feels a quiet sense of success. “I can feel good about what I accomplished in cycling,” he said. “I do feel like my work is done here as far as trying to clean up the sport.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed. 2016.07.003
Annals of Emergency Medicine 19A
I
t was near the end of a 123-mile stage in northern Italy when Christian Vande Velde crashed while riding his racing bike at 40 miles/hour. The star cyclist had finished fourth in the previous year’s Tour de France, and now the Chicago native had lined up to race the second most famous grand tour, the Giro d’Italia, in May 2009. Instead of battling for the leader’s jersey, however, he lay in the middle of an Italian road, his dreams dashed. Among those first on the scene was Prentice Steffen, MD, the chief physician of Vande Velde’s racing team, known as Garmin-Slipstream at the time. “Christian was involved in a very bad crash,” Dr. Steffen, an emergency physician, recalled in an interview. Later test results showed the rider had sustained fractures, including 3 vertebrae, his pelvis, and 2 ribs. But cyclists are used to enduring great pain, and with Dr. Steffen by his side, Vande Velde’s condition was stabilized and he received treatment in a hospital before returning to his home in Girona, Spain. Less than 2 months Volume 68, no. 3 : September 2016
later, he recovered enough to ride in the Tour de France, finishing seventh. Team physicians have had a checkered role in the history of the sport of cycling, as Dr. Steffen knows all too well. More than a decade before jumping out of a team car to attend to Vande Velde, Dr. Steffen had been a physician for the US Postal cycling team, for which Lance Armstrong would later ride and win 7 Tours de France (and subsequently be stripped of them for doping). After he raised questions about team doping in 1996, Dr. Steffen’s contract was not renewed, and he was replaced by “physicians” who prescribed drugs such as EPO in subsequent years. But now on the Italian roadside, working for the Slipstream team, Dr. Steffen had found gainful employment again for a cycling organization that actually wanted real physicians in the team car and in the hotels at night, looking after riders. His work as an emergency physician, one of the first in cycling, has led to 2 others joining the team to care for riders during a cycling season that lasts from January through October. “As emergency physicians, we are trained to be problem solvers,” Dr. Steffen said. “Whatever the problem
is, we need to know how to solve it. Almost anything can happen to the human body during a race, and we’ve got to be able to take care of it, or get the care started and find someone who can take care of it. Our profession is accustomed to working out of chaotic environments, and here we might be giving care with a hand out of a car rolling along, in the back of the bus, or in a hotel room. But never in a hospital.” Growing up in Oklahoma, Dr. Steffen always was involved with sports, running track and field and cycling avidly during his college years. Later, in medical school, his orthopedic surgery attending physician was Ted Percy, MD, who had been the chief medical officer for the Canadian team at the Montreal Olympics in 1976. He helped get Dr. Steffen a position at the 1986 Road Worlds Cycling Championships in Colorado Springs, CO. Later, while he was a medical resident from 1987 to 1990, Dr. Steffen worked several races, including the Tour DuPont and, yes, the Tour de Trump, named after the businessman and presidential candidate. By 1993, Dr. Steffen began working as a team physician, first for Subaru-Montgomery and then its successor US Postal, the team that Lance Armstrong would join in 1998. One of the defining moments of Dr. Steffen’s career occurred in 1996, at the Tour of Switzerland. Two of the US Postal riders, Tyler Hamilton and Marty Jemison, approached him and asked for information about administering performance-boosting drugs. The physician reported the incident to the team’s director, Mark Gorski. Annals of Emergency Medicine 17A
Dr. Steffen’s contract was not renewed at the end of the season, and the team hired the “Spanish guys” who, much later, were implicated in doping scandals. That was the end of it until 2001, when Dr. Steffen publicly recalled this story to David Walsh, a well-known Irish cycling journalist. Walsh’s subsequent story implied that Armstrong was part of a cycling team that condoned doping, and the Tour de France winner vowed to make Dr. Steffen’s life miserable. Armstrong got his chance 5 years later, after Dr. Steffen had linked up with a former cyclist, Jonathan Vaughters. Although Vaughters had experienced some success on the bike, he’d had to use drugs when he rode alongside Armstrong and others in the late 1990s. After that miserable experience, he’d started a “clean” team devoted to encouraging riders to race without taking illegal drugs, and the amateur team was then sponsored by TIAA-CREF. (It later would become the professional GarminSlipstream team that Vande Velde rode for.) Dr. Steffen served as the team’s primary physician. Shortly after Armstrong retired from cycling for the first time in 2005, the French sports newspaper L’Équipe reported on a research project that had retested 6 urine samples taken from the cyclist during the 1999 Tour de France. The samples were found to be positive for EPO. After that report, Dr. Steffen gave an interview to the French newspaper and was asked whether there was a certain type of rider who doped. “Unpleasant people like Lance Armstrong dope and nice people like Tyler Hamilton also dope,” Dr. Steffen said. At this time, Armstrong was essentially the godfather of US cycling, with influence over the sport’s ruling bodies and race directors in the United States. He 18A Annals of Emergency Medicine
telephoned Vaughters and demanded Dr. Steffen’s resignation. He got it. “That was a really dark moment in my experience with Lance Incorporated,” Dr. Steffen recalled. “We were just a budding team at the time, and Lance had some sway with some of our sponsors. He threatened to destroy the team. After a series of conversations, it was decided that the resignation had to happen, and Lance’s team wrote the apology I gave. JV [Vaughters] said as soon as this dies down, we’ll bring you back in.” Dr. Steffen returned to the team the next year. For team physicians at races, the days are long. On a typical day, they wake up early in the morning with the mechanics, who prepare the bikes for the type of terrain for that day’s racing, and the soigneurs, who provide massages for the riders, run errands, make sure the riders are fed during the race, etc. The physician will check on the riders during breakfast and make rounds before the bus leaves the hotel. After this transfer to the start line, the physician spends 4 to 6 hours in the team car. “Then, most days, nothing happens, and everybody’s happy when the team doctor has nothing to do,” Dr. Steffen said. After the day’s racing, the physician will contact the riders in the evening before dinner and bedtime. Hotels are assigned by the race organizers, and during a 3-week grand tour, that can sometimes mean 21 to 23 different beds in as many nights. It’s the whole spectrum, from amazing chateaus to “total crap hotels in a sketchy area of town.” The Tour de France organizers have a system by which they rank each hotel on its quality and, during the course of 23 days, try to even it out so that each participating team has roughly the same experience. “That makes us laugh because we know that when we’re in a really great
hotel that in a few days we’re going to be in a really shitty hotel,” Dr. Steffen explained. The team’s experience with Dr. Steffen has led to the hiring of other emergency physicians to care for riders. Of the team’s 4 physicians, each of whom rotates in and out for different races, 3 are now emergency physicians. The practice is suited to cycling not only because of the diversity of training but also because of the flexible shift work that emergency physicians do. Phil Stawski, MD, had worked in Lassen Volcanic National Park in California before meeting Dr. Steffen and joining the cycling team back in 2012. He started his tenure with a bang, serving as the team’s physician during the second half of the Giro d’Italia in 2012, which was won by the Garmin cyclist Ryder Hesjedal, a major breakthrough because it was the team’s first (and only) grand tour victory. The care delivered during the course of a cycling season covers much of medicine’s broad spectrum, Dr. Stawski said. In the spring, when some of the major 1-day “classics” are held on the hills and cobblestones across Belgium and France, allergies pose a major threat. During 1- and 3week races, the confined spaces of hotels and team buses, with 9 riders and 15 to 20 staffers, means that any gastrointestinal or upper respiratory bug can easily wipe out a team’s race chances. On the roads themselves, the most common injuries are lacerations and bruises from light crashes and breakages such as collar bones. Then there are the more rare but more serious cases of traumatic injury and cardiac arrest. “It’s everything you see in an emergency department but on a road, and in some very unique situations,” Dr. Stawski said. Quick calls must be Volume 68, no. 3 : September 2016
made: will tests in a local medical center be sufficient, or must a rider quit and travel hours away to a major hospital? Issues such as socialized medicine complicate the picture further. A physician must know what clinical options are available as the race moves across Europe, the Middle East, and other places. The team’s other board-certified emergency physician, Kevin Sprouse, DO, agreed with that assessment. Similar decisions must be made off the bike, too. “A lot of the medicine on these trips happens between stages, maybe with a late-night knock on the door when a rider has some belly pain,” he said. “We’ve got to decide whether this is a really serious thing, or maybe.just gut rot from too many energy gels.” Again, having a background in emergency medicine offers the perfect kind of preparation for these various tasks. In 2014, the Giro started outside of Italy, in Belfast, Ireland, with a team time trial. This is when the entire team rides together to get the quickest possible time around a course, with the team’s time based on the time of the fifth rider. Dr. Sprouse was the physician that day, and the entire team crashed, with broken clavicles and other injuries. It was Dr. Sprouse’s job to assess damages and to get riders healthy enough to ride because the clock was ticking for the entire team.
Volume 68, no. 3 : September 2016
“It was almost like a mass casualty scene, and as an ER doc we’ve all had those days when they roll in 5 or 6 ambulances at a time,” he said. “Being comfortable with that situation made it so that when I jumped out of the car I didn’t lose my head. It’s a little bit harder because you’ve got relationships with all of these guys, it’s almost like your friends are lying there, and you’ve got some competitive pressure. But I felt as prepared as I could possibly be for such a situation.” With the younger people coming through to serve as physicians now, Dr. Steffen said he’s planning to retire at the end of this cycling season. He’s been traveling to races around the world now for 24 years, and he will turn 56 in November. Dr. Steffen has tired of the long plane trips. He’ll have more time to work at the Dominican Hospital in Santa Cruz, CA, where he now spends half of his time. And Dr. Steffen can leave the sport feeling pretty good about things. Cycling is far from perfect. Cheating still occurs, but it seems far less prevalent. It continues to trouble Dr. Steffen how some team “physicians” use drugs that could harm young men to improve their performance. “It was really just unacceptable what was going on,” he said. “I suppose you can find people to do whatever you want them to do. But as
a physician, that was really hard to take.” With Vaughters, he’s had the opportunity to work for someone who valued clean riding, so Dr. Steffen could put medicine and rider health first and push ideas such as a noneedle policy, in which athletes cannot compete for several days after an injection. After all of the Armstrong mania, from his stunning rise to fall from grace and doping admissions, Dr. Steffen says he feels a quiet sense of success. “I can feel good about what I accomplished in cycling,” he said. “I do feel like my work is done here as far as trying to clean up the sport.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed. 2016.07.003
Annals of Emergency Medicine 19A