Sunday, May 12, 2002 - Information
The Doping Scandals of Salt Lake

By: Dr. Donald Christie Jr.

As the flame was extinguished at Salt Lake City many of us prophesied that the last page hadn't been written on the doping scandals, and the discovery of the used bags of blood and transfusion paraphernalia in the Midway, UT, house used by the Austrian team proved us right. It is "back to the future" in a couple respects, including one awfully close to home.

First, it recalls the scandal last year in Lahti, when a doctor's satchel containing used hydroxyethyl starch (HES) bags, needles, and IV tubing was found at a filling station near Helsinki, turned into the police, and then reclaimed by the trainer for the Finnish team. (Talk about shooting yourself in the foot!) Second, and even closer to home, is the disgraceful scandal within the U.S. cycling team at the 1984 Los Angeles Games, when, in an off-site motel, several members received transfusions of blood donated by family members, among others. A physiologist and a physician who had been working with the cyclists orchestrated that shameful episode. At least one American cyclist had to give back a medal and others were discredited ex post facto.

If one stops and reflects, it makes sense that all those Eastern Bloc physicians, trainers, sports scientists, and coaches that were so involved in state-sanctioned doping 25+ years ago didn't fall off the edge of the Earth. They simply hunkered down, "escaped" and ingratiated themselves with desirous athletes and coaches who were ready and willing to pay for their doping and concealment expertise.

Steven Ungerleider's Faust's Gold recounts the trials of former East German doctors who gave their athletes those "little blue pills." It unveils the shenanigans in just one Eastern country. A couple years ago, at the annual meeting of the New England Chapter of the American College of Sports Medicine, a New York Times reporter traced the trails of several of the Eastern "doping doctors" and put them right on site in Italy, Spain, and Sweden, among other places, where they were advising teams and individuals one might have considered "suspect" insofar as their performance improvements were concerned.

We don't have to go to Eastern Europe to find these villains now, however. Sports physicians and trainers from Italy, France, Spain, Holland, and Finland have been implicated in doping scandals, first in cycling -- and now Nordic skiing.

At last year's annual meeting of the American Medical Society for Sports Medicine, Greg Lemond told the story of his rude awakening to the pervasive use of performance enhancers among the European teams when, still a teenager, he for the first time traveled to Europe to get some overseas experience under his belt. The European riders would ask him and his U.S. teammates, "Where is your doctor?"

"Oh, he checked us out and then went home," Greg replied.

"No," they persisted, "Where is your doctor?"

"After a bit," Greg went on, "it dawned on me that they meant 'Where is your doctor who will manage your drugs?' They all had medical support that looked after those things!"

The Austrian scandal of blood bags in the trash raises an obvious question: Where did they get the blood?! It is not the kind of thing you simply order out from Pizza Hut. Did they bring it with them? (Unlikely, unless baggage inspection really isn't as careful as they say it is these days.) Did they sneak it out of some local blood bank? (Now that would be a story for the Deseret Times!) Did they collect it from previously tested donors among relatives and support staff (shades of the U.S. cycling team in Los Angeles!)? Did they collect blood from the athletes themselves a month before (a procedure often done in anticipation of major elective surgery), then reinfuse it just before the race up to a month later?

Any and all of these possibilities require the input of considerable knowledge and wherewithal regarding blood collection, typing, cross matching, preservation, and administration, and would involve substantial planning. Even then, there are serious risks in doing this on the sly and in such an environment. Most of the rules, regulations, and precautions pertaining to blood banking are not window dressing, but in place for good reasons of safety.

Sophisticated laboratory sleuthing can detect if someone has recently received a transfusion of another's blood, especially if that individual has never before received one. Similarly, one could match residual samples from the trash with possible donors and recipients, provided they could get samples from these individuals, who have no doubt long since jetted back to the Alps. It now seems the Austrians, by admitting that at least two team members received a blood transfusion, not just the absurd irradiation and reinfusion of withdrawn blood for health reasons, have saved the FBI and others the trouble of figuring out identities.

Perhaps some of the blood residual discovered represented blood drawn from athletes found to have too high a hemoglobin (Hgb) level on their own pre-race Hgb checks. We can assume that they were testing themselves, to see if they had overshot the mark, and one sure-fire way to avoid "official" detection of high Hgb is simply to bleed oneself enough to bring red cell levels back under the legal limit. (Over-hydration doesn't work for long, for the kidneys quickly excrete the excess water, kind of embarrassing when you're out in front of thousands of people, and as the Lahti Six found out, using other means to "dilute down" the Hgb will be detected.) The tubes and bags used for phlebotomy (the drawing off of blood) are the same types as used in administering collected blood and blood products.

Now that the "discovery" stage of the IOC investigation into the Austrian team saga is over, we await the conclusions from the correlation of testimony and forensic evidence. With the Austrians now admitting some illegal activity -- though not in medallists, they are quick to add, as if that lessened the severity of their crime -- we no longer find the Austrians in complete denial.

Their lame excuse that they were simply trying to prevent colds and speed recovery with their cockamamie irradiation methodology was ludicrous from the start, and they left themselves open to all kinds of state and Federal charges stemming from improper and unauthorized handling of blood and blood products, as well as practicing medicine without a (Utah) license. States usually give a wide, albeit unofficial, berth to visiting team physicians who typically lack local credentials, but this episode surely strained credulity as well as the letter of the law.

Just as WADA was on the lookout for HES and its breakdown products in athletes at the 2001 World Champs, so had WADA quietly been checking for the appearance of darbepoetin in samples collected throughout this past winter. The respected Danish sports physician Bengt Saltin is quoted as reporting that WADA monitoring had detected rising hemoglobin levels and high levels of reticulocytes (brand new red cells) in some athletes, making their use of erythropoietin (or in many cases now, the newer, longer-acting darbepoetin) highly suspect.

Reticulocyte is the name given to the brand new red cell, a day or less "old," as it is seen in the blood after being released from the marrow. (It stains in a manner different from the mature red cell and is easy to spot and count.) The proportion of reticulocytes to the "older" red cells -- known as the reticulocyte count, or "retic count," for short and expressed as a percentage of the total number of red cells in a given volume examined -- is thus an indication of the rate of the marrow's new red cell production. In a healthy person with a stable hemoglobin level appropriate for the altitude at which one lives, the reticulocyte count is 0.5 to 1.5 %, meaning that from just under, to just over, one per cent of our red cells are breaking down and being replaced every day. This orderly process is a function of the kidney's detection of the oxygen carried in the blood, the kidney then secreting the right amount of erythropoietin to signal the marrow to produce just enough red cells to replace the usual daily loss, about 1% per day. (Put another way, the average red cell life span is about 100-120 days. Thus we renew our red cell mass on a rolling average of about 1% each day.)

To then spot a higher retic count -- 2 to 2.5 to 3%, say -- in someone with an already normal hemoglobin (or one slightly higher than normal!), signifies that something "extra" is commanding the marrow to make red cells faster -- and it's probably not because the subject is on the last day of a two-week hiking trip in the Andes! Of course, when someone loses blood for whatever reason, and the body has sufficient iron stores to support accelerated marrow red cell production, then the retic count will be appropriately high -- 3, 4, 5% or more, depending on the amount and speed of the loss. However, the athletes being observed by WADA were hardly suffering from acute blood loss!

The tales of Salt Lake City continue, don't they, from traces of metamphetamine in an alpine medallist to an anabolic steroid detected in a Paralympian, to the Austrians' opening the door of the confessional just a crack? The last chapter hardly seems complete.

As if that weren't bad enough, Ezra Dore-Hart, a former Maine schoolboy skier, reports from Finland that idolatry for the Lahti Six seems to know no bounds, and several of the guilty proclaim their intentions to return to competition as soon as possible. If I were a competitor who had always played by the rules, and had given nothing but my blood, toil, tears, and sweat, I would forever feel uneasy lining up at the start with such types.

Dr.Christie graduated from the University of Rochester medical school in 1968 and received specialty training in internal medicine from the University of Iowa. He became a member of the American College of Sports Medicine in 1976, participated in an ad hoc study group that defined "sports medicine" and "team physician" in the late '70's, and was later elected to Fellowship in the College. He has served as varsity team physician at Princeton University for six years. For the past year, he has been devoting all of his practice time (and much of his "off-duty" time) to sports medicine and exercise science, with a particular concentration on Nordic skiing.

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