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May 2, 2008

Wild Western Medicine (Western States Diary)

As I was writing the latest installment of my Western States series, one pervading thought stuck in my mind: Olga's going to hate this.

She and I have exchanged enough blog posts and comments and emails for me to understand that she’s about as tough an ultrarunner as you’ll find anywhere. It must have something to do with her being Russian; in all likelihood, while I was growing up watching Bugs Bunny cartoons and eating Fruity Pebbles, she was doing … I’m not sure what, exactly, but probably something much more strenuous and character-building. Probably in the snow.

By now I’m used to her race reports describing determination and perseverance through conditions that would leave most of us curled up on the ground. And every time I write something about how difficult Western States might be, she slaps me with a comment like, “Stop complaining – it’s not that bad.” Her experiences have helped me temper the impending sense of doom I sometimes feel when thinking about all the things that could possibly go wrong on my journey from Squaw Valley to Auburn.

But I also felt that the topic of this article was an important one: namely, the staggering degree to which ultrarunners depend on countless medical personnel and other volunteers to provide a safety net around what frequently amounts to a 100-mile tightrope walk.

The runners need the medical folks – but in recent years, the medical community has also come to rely upon ultrarunners as a valuable source of information to enhance their learning. That’s why it’s unfortunate when members of the two groups find themselves in adversarial positions – as sometimes happens in the middle of an ultra.

If nothing else, I thought it was an interesting story to tell.

As for Olga’s reaction – I can’t tell you for sure what it’s going to be, but I’m happy to say that she and I will be able to discuss it in person. We’ll both be running at Miwok this weekend, and we’ll have a lot of miles to talk it over.

One final note before today’s article: instead of linking back and forth at the end of each post, I’ve started keeping an archive of this series on the sidebar at right. Check there to see previous installments, today or anytime.


Journey of 100 Miles: A Western States Training Diary

Part 3: Wild Western Medicine

“You look into their eyes and see if the soul is separating from the body.”
- Bob Lind, Western States Endurance Run physician, commenting on when to pull a runner from the race

One major distinction between road racing and ultrarunning, besides the obvious difference of race distance, is the degree of danger that competitors encounter on a regular basis.

All road racers, from 5K runners to marathoners, contemplate risk from time to time. We all know stories of runners who have suffered dehydration, heat stroke, or even heart attacks during the course of competition. Fortunately, the occurrence of severe incidents at road races is somewhat on par with the odds of getting struck by lightning.

Nearly every runner lining up at the start of a road race is reasonably certain that he (or she) will make it to the finish line; the only questions are how long it will take, and what condition he’ll be in once he gets there. Marathoners are often aware that something life-threatening can potentially occur, but such danger is typically only a small whisper in the back of their minds once the starting gun sounds.

For ultrarunners, on the other hand, that danger is a full-throated roar. It’s a threat that competitors have to stare directly in the face for hours on end, and one that frequently gets the better of many runners by the time the race is done.

At last year’s Western States run, more than 30 percent of the runners who started the race in Squaw Valley were unable to make it to the finish line in Auburn. The year before that, only 53% of the starters finished the race. Any year that sees a finisher percentage greater than 70% is considered a “good” year. These numbers aren’t unique to Western States – in fact, some ultras have drop rates approaching 50% annually.

Throughout the Western States course, there are medical checkpoints where runners are weighed and examined, and they must be deemed suitable to continue the event. This is another remnant of the race’s origin as a horse race; the Tevis Cup features veterinarians stationed at regular intervals to inspect the well-being of the horses.

(Interestingly, the annual dropout rate is slightly higher for the horse event than it is for the human one – which probably speaks both to the sensibility of horse owners, and the mule-headedness of ultrarunners.)

Running 100 miles in temperatures that frequently top 100 degrees isn’t something the human body is normally equipped to perform. There are countless physical maladies that can befall athletes attempting the feat – so many, in fact, that all manner of healthcare professionals are utilized to ensure runner safety. On race weekend, approximately 50 physicians and 100 nurses are available on the course along with podiatrists, paramedics, EMTs, chiropractors, physical therapists and massage therapists.

On a related note – if you’re a healthcare provider looking to drum up a little extra business, you’d be well advised to hang out in the Sierras during the last weekend in June. New clients might literally crawl out of the woodwork.

While the runners are in extremely capable hands during their 100-mile adventure, there’s definitely an element of frontier medicine practiced on the dusty trails during race weekend. Take blisters, for example – the bane of any ultrarunner’s existence, sometimes growing so large as to span the entire length of the foot or ankle. At Western States, the tried-and-true remedy is to: 1) lance and drain the blister, 2) squeeze a tube of super glue into the blister to fill the space once occupied by fluid, and 3) cover the whole thing with a big piece of duct tape. Isn’t that just how Doc Holliday would have done it?

(Before you laugh, consider this – it’s effective, and a lot cheaper this way. I mean … who needs medical supplies when you can accomplish the same result for $3.95 from the local hardware store?)

Speaking of blisters - Western States runners also make for such unusual case presentations that the race is included as part of graduate school study. Podiatry students monitor the course at various stations to witness all the disgusting injury manifestations that can result from running for multiple hours under scorching heat, through river crossings and across rocky trails. So I guess if the bottom layers of my feet start peeling off, my agony will be somewhat comforted by the knowledge that I’m making a small contribution to science.

Over the years, word has gotten around that common sense-challenged ultrarunners make for good lab rats. Consequently, many medical researchers have jumped at the opportunity to attend these races and conduct studies documenting how the body responds to various types of extraordinary stress.

Over the past few years, no fewer than 10 published medical studies have focused on Western States runners, featuring such ominous topics as immune system suppression, respiratory tract cell destruction, muscle wasting and severe inflammatory syndromes, and cardiac damage incurred during the course of running 100 miles. Researchers invariably find runners with physiological markers which under normal circumstances – say, if they wandered into an emergency room - would get them admitted to the hospital with IV fluids, a full metabolic workup, and a surgical consult.

The potential medical conditions that can develop are almost too numerous to mention - but a list of the most prominent concerns would include heat stroke, altitude sickness, renal (kidney) shutdown, dehydration and hyponatremia (low sodium balance), persistent nausea and vomiting, heart failure, hypothermia, and injuries from falling. Fortunately, most of these conditions are easily preventable if symptoms are treated quickly; the problem is that ultrarunners tend to ignore small problems – or for that matter, very large ones - even if their overall well-being is jeopardized.

The concern is magnified after darkness descends upon the race, when minor complications can rapidly escalate into threatening situations due to the runner’s increasing fatigue (both physical and mental), and the added difficulty of locating a runner in the darkness should assistance be needed. Therefore, medical personnel often find themselves with very difficult decisions to make when it comes to deciding whether to pull an athlete from the race. Usually, the person who argues against them the loudest is the runner.

Keep in mind that the folks who sign up for 100-mile events aren’t usually the type to withdraw from a race simply because they feel tired. Remember, these are crazy people we’re talking about. More likely, they are so driven and focused on reaching their goal that they will overlook or ignore potentially harmful symptoms in order to press ahead at all costs.

They’re used to dealing with pain. They can handle an enormous amount of physical discomfort. More than likely, they are willing to trade several days or weeks of recuperation for the chance of reaching the finish line under their own power. And when they get tired, they don’t often think rationally about the consequences of refusing the intervention that’s offered on the course.

Further complicating the issue is that most doctors who work the race have been shocked by the runners more times than they can remember. Nearly every aid station volunteer has a story of some runner who looked like death warmed over somehow finding the ability to rebound, gain strength, and finish the race after everybody had recommended a dropout. Ultrarunners are typically of the mindset that “it doesn’t always get worse” – meaning, if they can somehow ride out an extremely rough patch, they’ll feel better at some point further down the trail.

This philosophy is often a direct contradiction to a physician’s conservative instincts in protecting his or her patient from harm. So how do they determine when to pull a runner?

The introductory quote is about as accurate, specific, and scientific as you’ll find – which is to say, not very much. I guess they hope they’ll know it when they see it. And I hope I won’t find myself on the receiving end of such a decision.

A friend of mine is an emergency medicine physician. We’ve commented to each other that while it’s nice to have each other’s acquaintance, we hope to never encounter one another in an official capacity. When it comes to the medical personnel at Western States, I tend to feel the same way.

I’m thankful and grateful that those folks are out there, and I’m indebted to them for providing an environment that’s as safe as possible for runners under such unusual circumstances. Beyond that, I hope to never have the pleasure of benefiting from their expertise.

After all, I’ve got a race I need to finish.


triguyjt 5/2/08, 6:30 AM  

if we could all just use the super glue in the blister appraoch to medicine for wide sweeping concerns, just think how much of a dent we could make on the strangle hold, the insurance companies have on us.
do the super glue thing at your neighborhood hospital and its 300 bucks for the glue, and,,shoot they probably need to do an mri...wait...how about some kinda x-ray....
then post op therapy....

i love the part about the horse dropout rate being more than human.

Journey to a Centum 5/2/08, 9:11 AM  

Hey, don't know if you can help but Gretchen is looking for a ride at Miwok. Do you have a crew that might be able to help her out?


21stCenturyMom 5/2/08, 12:17 PM  

The ALT aid station will be chock full of medical people. Just bring those blisters on by! If we can get you out of there we'll probably see you at the finish line - yay!

olga 5/2/08, 3:18 PM  

I am honored:) You forgot the pain perception study. But, no, really, don't you scare potential participants with all those things! Somehow I missed this portion of the brochure my first year. I think been an MD helps not to focus on side effects - there is nothing life threatening (but hyponatremia), really! Blisters will ruin your race - but not life, so will dehydration and broken ankle. Learn to puke on the go and deal with it ahead of time (practice makes it perfect...hmm, ok, forget I said it). Drink, salt, food, watch your step 3 feet ahead of you and enjoy the journey! Actually, I glimpsed at your post just before heading off to airport, so a full new post (or at least a first paragraph) formed in my mind by now.
As for what did I do when you watched cartoons? Worked on the fields for potatoes and linen harvest, apples, strawberries, cherries (not for myself, for soviet coop) - manual labor, not enough adults (I grew up in military village in Belarus...oh, yeah tough love with my father!) Did I mention I built roads in Siberia? And yes, i did walk a mile to school through the woods in the snow:) Oh, c'mon, life is wonderful!

Rahn 5/2/08, 3:57 PM  

Hey, I want to get a blister just so I can try the super glue thing.

Thanks for all the great entries. I get a big kick out of them.

Bart 5/3/08, 1:24 PM  
This comment has been removed by the author.
Sarah 5/3/08, 1:26 PM  

I know its not the point of your post, but I wanted to point out that road racing and ultrarunning are not mutually exclusive. And while I love trail ultras the best, there are a lot of awesome road ultras out there too. : )

PreFan1982 5/3/08, 6:43 PM  

Western States is a dream of mine one day...thanks for letting me live it through you for now!

Addy 5/3/08, 8:48 PM  

Great writing :) Reading made me think...wow...that doesn't sound all that appealing (except...well...it still does :D)

Hope you have a blast at Miwok!

Rainmaker 5/4/08, 9:47 PM  

Interesting about the weigh-station checkin's, I didn't realize that. Facsinating post!

rick 5/5/08, 12:58 PM  

In the 2006 Western States, I suffered 16 blisters and was reduced to walking the last 30 miles mule-headedness is right ono the money! I've never tried the super glue method myself however, I'm sure I'll have plenty of opportunities in the future.

Can't wait to hear your first impressions of Miwok. Hopefully it was a good race and you were on hand to see the record broken.

SLB 5/6/08, 3:13 PM  

Another great post, this is all sound remarkably tempting...

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