Mike Mason
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Watch your fluids...and he was a Doctor...Subject: Hyponatremia hysteria and my day at the BH 100
>
> Hyponatremia Hysteria and How I Almost Ruined My Otherwise Fantastic
> Day = at the Big Horn 100
>
>
>
> Before I get into my public confessions of stupidity let me start off
> = with a few general observations about the Big Horn. The BH is a =
> fantastic event. When race organizers call this event "Wild and =
> Scenic," they are serious.
>
> First, as for the "wild" part, you are definitely out there. Other =
> than for an occasional dirt road, the Porcupine ranger station at the
> = 48-mile turn around, and the 5 miles of gravel road at the very end
> that = leads you to the finish line, there is no sign of civilization.
> It is = totally remote wilderness and it is awesome.
>
> Second, as for the "scenic" part, this is not exactly accurate -- and
> = possibly even a bit misleading -- as I would have to consider that
> the = understatement of the entire year. The course is flat out jaw
> dropping, = majestically gorgeous.
>
> The race directors and volunteers were great. The search and rescue =
> people were very well organized. When you combine the medical =
> possibilities with the remoteness of the Big horns, it is nice to know
> = that those folks are around and prepared to do what they do.
>
> Everything else that follows in this report will be open to great =
> dispute, but trust me on this one point. If you are an experienced
> 100 = miler, you will definitely want to get the Big Horn on your to
> do list = for the near future.=20
>
> On the other hand, if you are a first time 100 miler, you might want
> to = Google "Vermont" and "Ultrarunning" and see what you come up with.
>
> This is a story that involves fluid, salt, weight, and a fair amount
> of = stupidity, so let me start with a little background information.
> I am = nearly 50. I am 6'1". During the base phase of my year, my
> weight was = stable at about 168. My usual diet is rather strictly
> low carb. A = couple months prior to the BH I purposely endeavored to
> cut some weight = through even more strict low carb nutrition and
> increased running and by = Monday of race week I was down to 158 (a
> weight that I had not seen = since the 9th grade and 40 lbs down from
> my max weight 3 years ago). On = Monday, four days prior to the race
> I let my diet drift toward a normal = carb diet (but was not yet
> purposely "carb loading"). I weighed in the = day before the race
> after a normal breakfast and normal hydration but = before purposeful carbloading which I typically do the afternoon and =
> evening of the day before a race. The scale said 164. Since I was =
> wearing street clothes with long slacks, long shirt, heavy leather
> belt, = and heavy race buckle which was all estimated probably to be
> several = pounds more than my hot weather running clothes, it was
> decided that 161 = would be the official baseline race weight that all
> the medical check = points would have.
>
> So now I get back to the hotel and the carbofeasting begins. =
> Carbofood, carbodrink, and carboanything I can get my hands on that =
> seems reasonably healthy. I also drank 48 oz of V8 juice.
>
> The next morning right out of bed before any hydration or food my =
> weight had shot up to 172. I usually don't eat anything in the hours
> = prior to a typical early starting ultra. But the BH starts at 11:00
> = a.m. and so I had a gigantic breakfast at the hotel buffet. I
> hydrated = a "normal" amount and was peeing clear but not excessively
> prior to the = start. Unfortunately for this story, I did not weigh
> myself again just = prior to the start.
>
> So the race starts and I feel great. As I did not know that I would
> be = deeply sick that night and writing a story about it, I did not
> make any = notes about exactly how much I was drinking and how much
> salt I was = taking. Before being afflicted with hyponatremia phobia
> (of which I = will be pretty much cured by the end of this story) my
> usual habit would = be to drink about 30 oz of water an hour and
> sometimes more during the = day knowing that during the night my
> stomach would lose some enthusiasm = for intake and I would probably
> only be getting in maybe 15 oz an hour. = And that has seemed to work
> out OK in the past and my weight is usually = OK at the end of most
> runs. On this day with all the recent commotion = about hyponatremia
> swirling in my head I was probably drinking less than = my usual
> habit, but probably still getting in 24 oz an hour, about half = of
> which was plain water and about half of which was Hammer Heed off the = aid station tables.
>
> As for salt, I was definitely not low. I was doing about 1 Succeed an
> = hour and I may have taken slightly more than that, but not less. In
> = addition to that I had taken 1 Succeed with water shortly before
> bedtime = the night before. I had also had that 48 oz of V8 juice the
> day before. = In the morning between wake up and the 11:00 am start I had two =
> Succeeds along with rather normal hydration. My gigantic breakfast was =
> heavily salted. Along the run I had some nonquantifiable but generous
> = portions of salt from the aid tables such as dipping boiled potato =
> chunks in salt and rather heavily salting a boiled egg.
>
> So now I am about 7 hours into the race and pulling into the 30-mile =
> aid station, which is a respectable pace on this course for a
> midpacker. = I felt great in every way with no swelling, blisters or
> any other = issue. Relative to my abilities, I was doing well. Mile
> 30 is the = major Footbridge aid station that includes a medical check
> and weigh in. = I get on the scale. Uh oh. 174.bs. I 'm OK with
> that because I knew = that I was 172 when I woke up this morning
> before breakfast or = hydrating. The problem is that my official
> weigh-in race weight is = listed as 161.
>
> In contrast to my experiences at other races, the BH medical
> guidelines = bracket your weight from above as well as from below.
> Maybe in this day = and age that has become common at other races as
> well, but it was the = fist time I had ever had to worry about the
> potential for get pulled = from a race for being outside the weight
> bracket from above as well as = from below.
>
> The Big Horn race packet discussion of this starts out with rather =
> standard verbiage about weight loss. "A weight loss of 3% indicates =
> that significant dehydration has occurred and the runner will be =
> encouraged to hydrate back to their pre-race weight. At 5% weight
> loss, = the runner may be nearly exhausted and may be held by the aid
> station = until adequate hydration can be established by the runner.
> A 7 % loss = of body weight may be grounds for mandatory withdrawal
> from the race due = to the high risks of heat exhaustion or
> hypothermia while on the course = and the increasing risk of dangerous impairment of body functions."
>
> OK, so far that was all old news that I had read a thousand times =
> before. The medical guidelines went on -- and this was the new part
> for = me that may be the new norm everywhere now and I have just been
> living = in a hole. Of course I have read the endless discussions on
> the list = about weight gain and hyponatremia and so forth but I had
> not yet seen = that incorporated in a race packet's guidelines for
> removal from an = event. Apparently the BH had a runner go down a few
> years ago who was = hyponatremic and so that may have made the RDs
> more sensitive to that = issue.
>
> The BH guidelines go on to say, "Weight gain may also be problematic =
> indicating retention of water with the corresponding risk of
> dilutional = hyponatremia and possible seizures. Runners over 3% of
> their starting = weight will be queried further regarding their fluid
> intake and = urination history with particular attention directed to a
> participant = who has not been urinating during the event. Runners
> over 5% of their = starting body weight may likely be held for closer
> monitoring and = possible mandatory withdrawal from the race because
> of the risks of = hyponatremia and seizures from excessive water
> retention during an = ultramarathon event."
>
> So now according to my calculator, with an official race base weight
> of = 161, plus 3% is 165.8 lbs and plus 5% is 169 lbs and I am
> standing on = the race scale at mile 30 and it says 174 lbs. I am
> hoping that the = paramedic forgot his calculator. The number is well
> above the "possible = mandatory withdrawal" cutoff. The paramedic
> looks concerned. I'm = concerned about how concerned he looks. I try
> to do some quick = explaining. "Well you see, even though it says 161
> lbs on your official = medical print out and I do confess that that is
> indeed what I actually = weighed 24 hours ago, I had this little
> carbofeast and blah, blah, blah, = and 174 is actually probably pretty close to my actual starting weight =
> today .... He never actually said anything about sitting me down or =
> "mandatory withdrawal." But the feel of that was swirling in the air
> = and we both knew it.
>
> As it turned out the paramedic at Footbridge was a very nice and =
> flexible guy and he could see that I was feeling great so he let me go
> = after giving me some warnings about not gaining weight. I head out
> for = the strenuous and nearly continuous climb over the next 18 miles
> from = Footbridge up to the Porcupine ranger station. I am thinking
> through = what the medical people are going to do with me at the next
> check = station (which is Porcupine). Will they be as nice and
> understanding as = the guy at Footbridge or will it be some strictly
> by the numbers type = who will definitely have a calculator and see
> that I am in the = "mandatory withdrawal" zone and pull me.
>
> Due to a number of factors - work, family, and everything else - I
> only = get the opportunity to do a single 100 mile event a year. So
> when I am = in one, it's kind of important to me. I spend a lot of
> time thinking = about this one day (and a half) a year and I knew that
> whatever = happened, I would be remembering for a long time. I wanted
> no chance of = being pulled. So I came up with a plan, which, of
> course, all of you = will immediately recognize to have been very
> stupid (and which I will = never do again). My brilliant idea was to
> try to drop some weight to = keep the medical people happy by stopping
> drinking for a bit. "A bit?" = you ask. "How long is a bit?" Well
> as it turns out, it is a new = international measure of stupidity that I just invented.
>
> So "a bit" turned into one hour and then into two and then into three
> -- = nothing to drink. And I was sweating a fair amount, as this part of the =
> course is reasonably strenuous - all uphill. OK, so I know what you =
> are all thinking. "What an idiot. And the guy's a doctor. Where did
> = he go to medical school, the University of Quackville?" OK, give me
> a = break. Doctors in general don't know jack about ultrarunning. I
> am not = writing this as a doctor. I am writing as someone who is
> trying to = learn to be an ultrarunner. And I am confessing publicly.
> It was very = stupid. So let's get past that and get on with the story.
>
> I still felt great through that three-hour period. But about that
> time = I noticed that I was a bit nauseated. I decided that I had
> almost = certainly lost enough weight and that the medical people
> would see that = at least it was going in the "right" direction and would not pull me.
>
> I intended at that point to get back on a more or less normal drinking
> = schedule. But something moderately wrong was going on with me by
> that = point and I couldn't make myself drink. Finally at one aid
> station I = was able to force a cup of rice soup and at a later aid
> station I forced = a small bowl of ramon and a couple of peach slices.
> Other than that I = had no food or fluid for the entire 18 mile 7 hour ascent to Porcupine.
>
> I was feeling like moderate crap but through some form of mental =
> gymnastics was able to keep up with a small group of midpackers I had
> = hooked up with. I did fall off the back of the group over the last
> mile = or so leading into Porcupine but was still moving forward at a
> = reasonable pace.
>
> As I arrived at Porcupine the very helpful volunteers took over and =
> guided me to the medical check in. My inner feeling had degraded from
> = moderate crap to feeling like total crap. I tried to put on a good
> face = so as not to draw any excessive attention from the medical
> staff. I = step on the scale. 174 lbs. What!!!??? After 7 hours of
> strenuous = climbing with significant sweating and almost zero intake
> of food or = fluid and I am still 174!?
>
> I know that I just need to sit down and let my motor power down so I
> can = think this through. I, like I think everyone else who does
> ultras, have = been sick many times before, but with minor adjustments
> and simple = remedies I can usually pull out of it quickly. I sit
> down and the = cheerful volunteers come by to see what they can get
> me. Everything = they offer seems revolting. I can take nothing. I
> arrived at 1:00 am. = The cut off to be back out the door is 5:00 am.
> I know that I have time = to engineer some kind of recovery.
>
> After about 5 minutes a very nice paramedic kneels beside me to
> discuss = his concerns about my weight and the dangers of
> OVERhydration and = HYPOnatremia. I have just climbed 18 miles over 7
> hours with = significant sweating and near zero oral intake and the
> fricking scale is = alerting the paramedic that I am OVERhydrated!?
> And now based on that = possible misinformation the paramedic has the
> potential to give serious =
> health- and/or life-threatening misadvise!=20 =20 This is not the
> paramedic's fault. He was very professional. This is a = system
> problem. There are numerous variables that are potential sources = of
> error that affect information that is given to a paramedic who up in =
> the cold, dark and remote Big horn mountains is looking at runner #628
> = (me), who he knows nothing about other than that the computer sheet
> says = that he should weigh 161 and right now the scale says that he
> weighs = 174, he looks like total crap, and he may need some help.
> But what = exactly is runner #628's problem and what advice or action does he need?
>
> And after reading the introductory part of the story, the question
> that = I would pose at this point to all of you reading this is, what
> weight = should have been on this paramedic's sheet so that he would
> have a = chance to make a proper assessment? My normal 158? My 161
> at race = registration? My 172 on race morning after carboloading the night =
> before but prior to hydrating and eating that morning? Or 175, which =
> is probably about what I weighed at the actual moment of the start?
> The = actions of race medical staff could be totally inappropriate or
> even = life threatening depending on the number they pick and the
> actions that = that number prompts them to take.
>
> And then there are the numerous variables with potential for error =
> within the race. I won't even consider here the potential variability
> = between scales. Let's assume for the sake of discussion that at
> least = the scales are identical and accurate. On the BH course,
> Footbridge is = in the lower hot canyons run during the daytime.
> Runners are dressed = minimalistically for the heat. Porcupine is
> high up and typically hit = in the middle of the night and is cold and
> the runners would typically = be in long tights, upper layer(s),
> jacket, hat, gloves, with shoes and = socks soaking wet and covered
> with mud. The runners obviously are not = stripped for the weigh in.
> If you added up all those items, add in the = sweat and soaking and
> mud, and that one source of error alone could = easily exceed 5 % of one's body weight.
>
> So back to the story. I weigh in at 174 and the next thing I know I
> am = being questioned about whether I understand the dangers of
> OVERhydration = and HYPOnatemia with the unstated implication that I
> need to cut back on = my fluids.=20
>
> I have felt mild or moderately sick many times before during an ultra.
> = But this was different - I was deeply sick. I had an inner
> intuition = that told me that if I just got up and ran out the door
> and continued = on, that something really bad could happen. Can I say
> it (I know that = this is an exaggeration)- I felt that if I went back
> out that I could = die. So I didn't do that.
>
> I knew I had some time on the cut off. I also knew that I wasn't
> going = to drop. If they had to rip the race number off my shirt at
> 5:00 am, = then so be it. But for now I was still in the race and I
> still had 3 = =BD hours until the cut off.
>
> I asked the paramedic if there was a cot for me to lie in. He took me
> = up stairs to a cot. I rested for awhile and even slept for a short
> bit. = I was still deeply sick. I knew I had to get fluids and
> calories in. = I was given some Hammer Heed, which was the aid
> station drink. It had = tasted fine earlier in the day. Now I tried
> a slight sip and had = revolting nausea. I was given some diced
> boiled salted potatoes. I = tried to force myself to eat but could not even take a nibble.
>
> What HELL is wrong with me!!!??? I only had about 2 brain cells
> working = and at 3:00 am even those two were half asleep. Could I be
> overhydrated = ? No way - despite what the scale may have suggested.
> Could I be = hyponatremic? No way. Could this just be good
> old-fashioned simple = dehydration? Possibly, but can simple
> dehydration make you feel this = deeply sick? I couldn't remember.
> Could this be HYPERnatremia? Yes, = possibly. I probably was indeed
> excessive with my sodium intake in the = hours prior to the race and
> in the race itself in the hours leading up = to my stupid decision at
> Footbridge to cut fluids. Could this be renal = failure? I hoped
> not. Could this just be severe glycogen depletion? I = didn't think
> so. I have never seen anyone this sick just from glycogen =
> depletion. Was I just being a pussy? No, I was not just being a pussy. = Something was seriously wrong with me.
>
> So my two remaining brain cells decided that the most likely
> explanation = was dehydration and hypernatremia with severe glycogen
> depletion being = part of the situation I had to deal with but
> probably not related to why = I was so sick. I had a volunteer fill
> my 24-ounce bottle with plain = water. Without too much forcing I was
> able to get the whole thing down. = Someone else brought me a cup of
> water-based hot chocolate. I managed = to get that down as well.
>
> After about 15 minutes I noticed that my sick feeling was modestly =
> lifting. Yes! I am still sick but I can tell that I am finally
> moving = in the right direction. Hope is rising. I started to work
> on another = bottle of plain water. After another half hour I was
> still modestly = sick but I was out of deep sick and definitely
> rapidly improving. I = began to get organized with the assumption
> that I would be out the door = very soon. At 4:00 a.m. I went out.
> Within 100 feet I began violently = shaking. Crap! Now what? I went
> back into the ranger station. It was = 4:00 am and cold and my motor
> had been shut down for 3 hours. I am = hoping that that is all it is.
> I put on an extra top layer and gloves = from my drop bag and headed out. Within 500 feet I felt just fine.
>
> Despite what the scale said, I knew that I was in a deep hole in
> regards = to fluids and calories and that I had no time to waste for
> the rest of = the day. I did what I should have done from the start
> and put myself on = a strict timed schedule for fluid and calorie
> intake with my watch = beeper. Since I had some suspicion of
> hypernatremia, I decided to take = no sodium over the next 6 hours,
> and then I would reassess my plan. I = am feeling better by the minute.
>
> Fast forward one hour.... It is now 5:00 am. The sun is on the =
> horizon and I am in a state of irrational exuberance. I feel awesome
> in = every way. Energy - high. Emotions - high. Leg turnover -
> high. = Speed - flying (relative to my ability). I am soaking in the
> majestic = beauty of the Big horns. My arms are intermittently in the
> air in a = hallelujah-like pose praising God for the incredible beauty
> around me = and deeply thankful for the gorgeous morning bursting to
> life before my = eyes. I know that the caffeine that I had as I left
> the ranger station, = which was the first I had had in over a month,
> probably helped my = spiritual exuberance and I am very thankful for that as well.
>
> Now fast forward again about 30 miles after hydrating well throughout
> = the day and now in minimal warm weather clothing at the Dry Fork aid
> = station, mile 82. I weigh in at 165 lbs. I was not completely
> happy = about that, but at least it made sense. I can only imagine
> what my = weight was last night at Porcupine. But I can tell you one
> thing - it = was not 174.=20
>
> If I can digress here for a moment, I would just like to point out an
> = aspect of the story to the yet-to-be 100 milers who may be reading
> this = that is old news to those of you with long experience at that
> distance. = In addition to giving me the opportunity to rethink my
> approach to fluid = and electrolytes, my experience during the night
> reinforced a lesson = that, again, most of you already know - don't
> quit. If time runs out = and they rip your number off, that's one
> thing. But when there is still = time on the clock, you never know
> what can happen. Recovery happens - = body, mind, and spirit.
> Engineer recovery. Focus on recovery. Know = and accept ahead of
> time that body, mind, and spirit will cycle. = Sometimes you will be
> on the joyful side and other times you will be in = despair. Accept
> ahead of time that times of despair happen and then = figure out how to engineer a recovery.
>
> I have observed it to be not uncommon to see a runner in some deep
> state = of utter misery drop out and then to see that same person a
> few hours = later volunteering at an aid station down the trail
> looking fresh as a = daisy - that is, recovered. If they would have
> just paused for a bit = before turning in their number, they may have
> bounced back to finish an = enjoyable day. But their number is
> already turned in and it's over. = Until the clock says it is over, it ain't over.
>
> I don't want to drag on this point about quitting or not quitting =
> because maybe to some people it is not that important. But another =
> thing to consider about quitting is that it does not just affect you.
> = It also affects those around you. When my three girls see their dad
> = persevere through adversity it affects them. Even if I didn't say =
> anything in words, many things just rub off on them. But, of course, =
> we do talk about it. It is like dropping a pebble in a pond - it has =
> all kinds of ripples beyond you. At 3:00 am in the ranger station and =
> deeply sick, the thought of DNFing came to my mind and a number of =
> unpleasant things flashed by - this was to be my qualifying run for
> my = automatic entry into Western States next year, my brother in law
> had = driven all the way from Albuquerque to run the last 18 miles
> with me, I = had looked forward to this event for a whole year, it
> would be such a = disappointment to have to tell all my patients and
> other people around = town that I didn't make it, etc., etc. But all
> these things that = flashed before my mind paled in comparison with my
> concern as to how the = outcome of the story - whether dad would
> persist in the face of = adversity or just quit - would affect my
> girls. Because one way or the = other, it would have an affect.
>
> So the race went on and I had a fantastic day. I felt great the rest
> of = the way other than a few brief episodes of pukiness. Although I
> am = turning 50 this summer, I am still getting stronger every year
> and I = could definitely sense this throughout the day. I don't
> really know any = ultrarunners. There are no other ultrarunners in
> Twin Falls, Idaho = (other than an old timer, Burge Harmer, who moved
> to Twin Falls a couple = years ago who happens to hold the record for
> the most grand slams, but = who retired from ultrarunning in 2001). I have never had a =
> pacer--partially because I don't know any. My brother in law Gary =
> Seaton, whose company I greatly enjoy, is presently training for his =
> first marathon and his longest run up until the BH had been 10 miles.
> = He wanted to experience an ultra so he met me at the Dry Fork aid =
> station with 18 miles to go and ran in with me. We had a blast.
>
> To top the day off, in the last mile Hans Dieter was just ahead of me.
> = I decided that it would be fun to totally blaze the last mile. I
> turned = on the jets and blew past Hans. He called out "Hey, hey what
> are you = doing? Let's finish this together." There was one other
> guy nearby who = joined us. This was Hans' 99th 100-mile finish and
> next month Hardrock = will be his 100th 100 miler and I would imagine
> that most of the people = already at the finish in the park knew this.
> So as we entered the park = the applause erupted for Hans. It was fun
> for me to be along for the = ride and the excitement and to cross the
> finish line holding Hans' hand. = A perfect end to an excellent day.
>
> I am inspired by people like Hans. I am not fast or talented in any
> way = and I can't really identify in any way with the elite fast guys.
> I am = awed by guys like Karl Meltzer but at the same time can't
> really see = much of myself in him - he is just in a different
> category. He is such = an aerobic machine, has so much shear
> athleticism, and drinks so much = beer - how could I ever measure up
> to that? While I will never be in = Hans' category either, there is
> something about seeing him out there at = age 67 that inspires me and
> gives me a vision of my own future. It = helps me see myself out
> there at 67 in the wilds of the Big horns with = Hardrock coming up the next month.
>
> So what did I learn and what will I do differently next time?
> Firstly, = I do know that hyponatremia is a potentially serious matter
> and I don't = want to down play that or take it lightly. But from my
> perspective, as = one who supplements sodium on a schedule, an
> excessive focus or worry = about getting too much fluid can, and I think did, put my safety at =
> greater risk than if I were to completely ignore the issue altogether. =
> I know, of course, that it is unwise adhere to either extreme, that
> is, = to "excessively focus on" or "completely ignore" the issue. So
> what = will I do? I will continue to supplement sodium on a schedule
> that = seems right for the conditions and I will drink generously
> according to = both my thirst and a schedule that estimates about what
> I think I should = be requiring given the conditions at hand. And
> then I will probably not = give too much further worry to the
> possibilities of hyponatremia. =20
>
> I will be interested to hear the thoughts on this matter from the =
> numerous more experienced and wiser runners on this list.
>
> Rick Sandison
> Twin Falls, Idaho=20
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Ernie
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I used to believe that nothing exceeds like excess; well there are exceptions.
Top article, a little long but worthwhile if one has the patience.
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