Ask the Doctor: The medical risks of doping
By Dawn M. Richardson MD FACEP
Aug 23, 2007 – In June I discussed my concern regarding psychological effects of use of performance enhancing drugs. I had also heard from some of the riders about medical injuries related to doping.
On Monday August 13th, Joe Papp, addressing a South Florida high school coaches’ conference on behalf of the U.S. Anti-Doping Agency, discussed the doping-related medical complications he encountered in July of 2006.
I asked Papp to tell me more about his injury to illustrate the medical dangers of doping. These are injuries the riders keep to themselves as part of the shame and secrecy of doping. Realistically, most of those involved in doping are using many products at the same time and for long periods of time before they are caught. They are currently penalized for one positive test per substance. That means that there is a built-in disincentive to be honest. Indeed, if a rider were to reveal the whole ugly story he or she would risk being charged with a second (non-analytical) positive and a likely lifetime ban from competition.
My goal here isn’t to educate dopers on how to become smarter dopers. Frankly, after looking at what Papp went through, I hope that sensible riders will understand the inherent risks involved in doping and, maybe if we’re lucky, eliminate the temptation. As a physician I find these stories appalling, and view the people involved in supervising doping in the same ethical category as back alley abortionists.
VeloNews: As I understand it you were taking EPO, found out you had a much higher hematocrit than expected and went on a blood thinner to attempt to avoid the risk of a blood clot or other complication resulting from high hematocrit. Exactly how high did your hematocrit go?
Joe Papp: 58
VN: Did anyone suggest the blood thinner to you such as a medically-trained person?
JP: It was suggested to me by my team director, who was not medically-trained.
VN: Did you have any medical supervision at this point?
JP: Only lab controls, which were not analyzed by a doctor.
VN: Why the blood thinner instead of simply pulling off a unitof blood?
JP:At the time, it seemed easier to take a pill than to explain to a doctor why my hematocrit was 58 and needed to be reduced.
VN: Was it Coumadin (Warfarin) or low molecular weight heparin?
JP: I don’t know.
VN: What was the thought process behind the blood thinner?
JP: It was thought that it would decrease risk of a cardiac event that could have resulted from the ultra-high viscosity blood.
VN: How long were you on the blood thinner?
JP: Several weeks.
VN: Were you racing while on the blood thinner?
VN: Was anyone checking your INR, PT or PTT (“ProthrombinTime” and “Partial Thromboplastin Time” are measurements of the blood’sability to clot – editor) to see the response tothe blood thinner?
VN: Did you have any idea what would happen to you if you fell?
VN: What did happen to you when you fell?
JP: Nothing immediately. In fact, I rode 20km home after therace (in which I’d finished fifth or sixth). But within hours theinternal bleeding had caused the appearance of a hematoma that all butparalyzed my left leg.
VN: Was it a routine fall that should have been no big deal wereyou not using EPO and blood thinners?
JP: Oh for sure. I fell going uphill in final 500m of a racethat I should have won. Was with three other riders, including ateammate. We started attacking on the climb and another rider tried topass me tight on my left and knocked my handlebars.
VN: What did they have to do in the hospital to fix it?
JP: Ultimately, I underwent surgery once they stabilized me.I was in hospital for seven days, the operation was in the final days afterit became apparent that the quantity of blood was too great for the bodyto reabsorb.
VN: Did you have to admit exactly what was going on in orderto receive proper treatment?
JP: Not really, but when I explained that I was a cyclist theyknew. They turned a blind eye to give me the care that I needed.
VN: How much blood did you lose into the hematoma?
JP: I believe the quantity of sludge that was removed surgicallywas close to 1200mL – is that possible for a horrible internal hematomain the gluteus maximus?
VN: Yes it is. You basically lost one fourth of your blood volumeinto what should have been a trivial bruise because your blood was waytoo thin from medically unsupervised and incompetent abuse of anticoagulants.This would put most people into class 2 hypovolemicshock.
How scary was all of that while it was happening?
JP: At the time, not very, because the medical care was excellent.What was scary was being alone in a hospital in Pescia, Italy, abandonedby my team and facing the end of my cycling career and a cloudy future.
VN: Do you understand what would have happened if you had hityour head?
JP: I eventually did, but I preferred not to think of dying.
VN: Did you have any other ill effects besides the hematoma fromthe loss of blood volume?
JP: Ancillary effects like major headaches, dizziness, temporarilyhigh blood pressure.
VN: Those are signs of class 1 hypovolemic shock. What did theyhave to do in the hospital to stabilize you?
JP: I came in first to the ER, and was put given an IV narcotic painkiller and then began a process of stabilization that I don’t remember very well.
VN: Did they give you any drugs such as Vitamin K to reversethe anti-coagulation?
JP: I don’t remember. Once I started on the IV morphineor whatever it was, after I’d given my entire medical history (much tothe horror of the team massage therapist who dropped me off at the hospital),the docs knew what they were dealing with and treated me accordingly. Thedoctors must have felt sympathy for me and wanted to do what they couldto restore my health and get me into a position to be able to leave Italyand sort out my life without having to take the fall (no pun intended)for the cheating being done by my entire team.
VN: Did they tell you your initial hematocrit or INR when youwere in the hospital?
JP: I told them what my crit’ was. I’d had it tested twodays before the race in a full lab work-up.
VN: Any other medical complications while you were doping thatyou care to discuss?
JP: Secondaryadrenal suppression. Horrible. Ruined half of a season.
VN: Do you get that if you’d had adrenal suppression and thehematoma at the same time you would have come home from Italy in a box?
JP: The adrenal suppression was in 2005… learned a lesson fromthat one.
VN: That’s a really tricky diagnosis, especially if the patienthas a reason to withhold medical information. I can easily see myselfscrewing up the diagnosis and having someone die right in front of me.I live in fear of undiagnosed adrenal insufficiency or Addisonian crisisand so does every other ER doc. John F. Kennedy, for example, hadprimary Addison’s disease and it’s why he was so sick all the time.
JP: I was not medically supervised in the period leading up tothat sickness but did finally seek treatment from an endocrinologist.
VN: Are you willing to tell me what products you were using,for how long and what symptoms appeared that lead to the diagnosis?
JP: Corticosteroids. For several months. I had majorfluctuations in blood sugar and was able to figure out what had happened.I ended my season early, but got the diagnosis from the endocrinologist.
VN: How long did it take for the adrenal suppression to be correctedwhile in treatment with the endocrinologist?
JP: It took over a month to restart the pituitary and getthe adrenals back on line.
VN: This really is health care gone way wrong and I find it frightening.Why didn’t anyone know about you? How is it that you became the “missingchild” face on the USADA milk carton?
JP: I kept my head down in the USA when I was here, and spentmost of my post-2001 career racing outside of this country, with foreignriders. For a long time many U.S..-based racers who saw me at events hereand read my on-line diaries thought I was not U.S.-born and maybe fromLatin America, maybe Argentina. There’s also almost no doping control incycling in the U.S., so it’s not like one lives in fear of returning apositive test at anything but the biggest races.
VN: How do you respond to naysayers who complain you’re justa small fish making a big stink, that you were a low level pro who is onlyspeaking out after he was caught?
JP: I don’t have to respond to them, do I? (laughs)Seriously, I don’t have anything else left to lose, so I’m in a positionto be able to speak out without fear of retribution, unlike someone likeBasso, who can still earn millions after his suspension. It all comes downto money – when a rider still has the chance to earn more money throughcycling than another profession, it is in his interest to deny specificcharges against him or general claims of doping in sport.
However, given that I will never race competitively at the internationallevel again, and I can make more money over a longer period of time workingin a professional field outside of cycling, there is no reason forme to fear retribution. So that frees me to speak out. I don’t have anyill-will towards the sport of cycling, nor do I have any anger that I’mtrying to exorcise by speaking. Rather, I care very deeply for the sportof cycling, and I know that I’m in a unique position to eloquently andeffectively speak about the negative experiences I had, hopefully for thebetterment of the sport.
VN: Thanks for speaking with us.
JP: You’re welcome.
By no means do I wish to sanction supervision of doping by physiciansin a misguided attempt to make it safer. All doping products havean inherent risk of use even in their intended, legitimate non-doping applications. This is why they are only legally available with a doctor’s prescription and supervision. Even the best and brightest physicians will putperformance ahead of athlete safety once they have compromised their ethicsand become involved in doping.
The creation of the World Anti-Doping Agency in 1999 had the almost-immediateeffect of dismantling of team-supervised doping. Unfortunately, in manycases that has simply driven doping further underground to the point thatthere is often no medical supervision at all. Directors, soigneursand athletes are playing Russian roulette with medical products they haveno legitimate business using and no education in how to anticipate or managecomplications of misuse. Drug testing is scarce at the lower levels ofprofessional cycling and nearly non-existent in second- and third-worldcountries. This is the final frontier of doping, a far more dangerousplace than ProTour doping, and there will be deaths and near deaths asa result.
“You are so focused on the travel, the training, the money and whata wonderful life you are having that you don’t realize how far down theslope you have slid,” Papp told the New York Times last month.
On a much lighter note I’m on a one-woman crusade to turn VeloNews.com into a cycling version of a ladies sewing circle. Here is a link toAaron’s Cycling Team’s CandaceBlickem’s photoblog of American professional cyclists, either pregnantor new moms, who have taken time out of their busy racing schedules thisseason to create the next generation of top pro cyclists.