Sunday, October 19, 2008

Tales from the Med Tent

Yes, the guy I am standing next to is in fact Andrew Baldwin (The Bachelor). He was leaving his shift as I was coming in. Not a big TV fan so I wasn't star-struck, but I did recognize him. Seemed like a really nice guy. Probably too nice to be subjected to the nastiness of that awful TV show. Blech.

OK, onto the report!

My shift was the 8pm-midnight. At Kona that is pretty much closing time from the get-go. If you're in Kona you're likely <13 hour finisher so it wasn't the busiest shift of the day. I didn't get a doctor's smock because I don't have a medical degree yet, so I was a "runner" for the night. My job consisted of running to get soda, water, crackers, barf bags, blood samples, test results, and anything else the athletes or docs needed.

I'll just talk about 2 of our athletes in the tent here, as examples of two completely opposite ways to mess up your nutrition and end up needing medical assistance: Underhydration and overhydration.

She walks into the med-tent and doesn't want to sit down. She paces back and forth for several minutes and then sits down, a little disoriented and starts to vomit. She's fidgity and can't keep anything down. We weigh her and she is up 13 pounds from her pre-race weight


(rant on)

Someone really dropped the ball this year with athlete weights. Rather than make everyone weigh-in, they let athletes write down their weight if they knew it. DUH! Come on people, do you really think that a triathlete woman is going to choose to step on a scale? No freaking way. And they will also underestimate their weight when asked. They didn't institute the weigh-in rule for intellectual curiosity, they did it because it is extremely helpful to the medical staff after the race. This blunder made weight pretty useless to us.

(rant off)

We took a small sample of the athlete's blood, concerned about her sodium level. I waited for the test results because we were all a little concerned about her, especially given the presumed weight gain. Her sodium level was 121 (normal 135-145). She was very hyponatremic. We have her lay down and start an IV of hypertonic saline (concentrated salt). She is a little bit disoriented and agitated and can't stop moving her legs. She says she feels like if she stops her legs from "running" her hips and butt will cramp. We give her some Benzodiazepines which stop her legs for a minute, but then she starts again.(*one indication for benzos is to abort or prevent seizures, a serious side effect of hyponatremia) A repeat sodium was taken 30 minutes after her salt infusion and was just mildly improved. Another IV of hypertonic saline is started after giving her some magnesium for her cramping. Another dose of benzos settles her down. She has stopped vomiting and is starting to clear up. She sits up and is feeling better, finally. A couple hours after entering the med tent her kidneys kick back in and she starts using the bathroom. Regardless, given how serious her condition was, she is sent to the hospital for observation overnight.

Why does this happen? The biggest contributer is over-drinking of free water. People think they need more fluids than they actually do and force drink throughout an event. The longer the event, the greater the risk. Gatorade endurance would definitely help with this since it has a lot of sodium, but not completely foolproof. Another culprit here is excessive sodium loss. People who have one copy of the recessive gene for cystic fibrosis (I think it's about 1/32 in the US population) lose excessive salt in their sweat. These people are more susceptible than average to excessive free water intake during sports events because in addition to diluting their blood with water, they are taking more salt away through sweat. Thirdly, there are hormones released when the body is stressed or in pain that actually reduce the clearance of free water from the kidneys. Some think that the pain of an Ironman is enough to induce SIADH , which in itself can cause hyponatremia.

What is the big deal if your salt is low? Well, the big deal is that it forces water into your brain down the salt gradient. Your brain is in your skull, so there's not much room for expansion. People are at risk for brain herniation and death. Did anyone here read about the radio station that was having a "hold your wee for a wii" contest? A woman in the contest, which was to see who could drink the most without peeing, died in her home a couple hours after the contest. Hyponatremia is a big deal.

Scenerio #2

Man walks into the med tent about an hour after the race saying that he started to feel dizzy in the food tent. He weighs in 3 pounds under pre-race weight. As he sits down and is talking to us he says it seems like he is blacking out. His blood pressure is 70/40. His face has no color. A 1 liter IV of fluids is started and he briefly passes out. He drifts in and out as the first liter goes in and still doesn't feel steady to stand after the first liter. As the second liter of fluid goes in the color comes back to his face. He is given a third liter before feeling back to normal and has a normal blood pressure.

This is a pretty classic case of hypovolemia. When you see this in the Emergency Department you immediately think that the patient is bleeding somewhere and losing blood volume. At the Ironman, it's much, much, much more likely to be fluid loss from inadequate fluid intake and excessive sweating. Most people who finish an Ironman are going to be slightly fluid depleted. Immediately post-race you will see many, MANY people cross the finish line, stand around, and then get dizzy and pass out or nearly pass out. This is because they are dehydrated and then when they stop moving and pumping those leg muscles blood pools in their legs. All you really need to do for these people is put their feet up for a few minutes until their body re-equilibrates. That is why the Ironman medical tent has a "weak and dizzy" area.

When people get into trouble like the athlete mentioned above is when they have lost more than the normal amount of fluids and also don't feel well enough after the race to replace the fluids they lost during the race by mouth. Maybe they are sick to their stomach from all the sugar, or just completely exhausted. These people will need IVs to get back that fluid volume. Most likely that will perk them right up and they can limp home

So these are two athletes that I saw at the race that were sick for opposite reasons, but both were able to be brought around by the great medical staff in the tent with no serious complications.

Oh, and all you athletes out there- GET ON THE SCALE BEFORE THE RACE! No one is going to look down on your for being over your race weight (I've been there. I weighed in at 130 at CdA which is pretty huge for shortie me). And it will help YOU out if you get into trouble on the course.

As the night went on the tent got quieter and quieter. We could hear Mike Reilly doing his countdown to midnight and then call in the last "finisher" (in quotes because it was after midnight) who finished several minutes later. The ambulance was called to take a few people to the hospital and the crew was already taking down the tent. There was a SUPER sweet nurse who was a native Hawaiian who gave me a big hug and told me she would see me next year. I left the tent, 20 hours after waking up that morning, totally exhausted!

In all, working in the med-tent was a great learning experience and a ton of fun. The athletes were very gracious and happy and there were a lot of smiles to go around. I WILL do it again, and next time I will be wearing a doctor smock!


ChrisM said...

As someone who was treated in the med tent at IMAZ, thanks for being out there. We appreciate it :)

Maggs said...

great report. I thought it was strange when they asked me to write down my weight instead of weighing me, because in Arizona they were insistent on weighing. But I had just been weighed at the expo. I know someone who gained 13 lbs last year during Kona. One look at her at the finish line and she was PUFFY.

D said...

At IMC this year one of the scales was weighing people about 10 pounds heavier than they actually were. For some reason the volunteers just kept using this scale. I asked them if I could use the second one they had "just to make sure", and it was accurate (I had actually brought my own scale for the hotel just to make sure I didn't go taper crazy so I knew scale #2 was right). Of course, all those people before me weighed in wrong - and I'm sure they just kept weighing people in on the wrong scale after me.
Hopefully this kind of goofiness gets sorted out for next year!

TJ said...

Great report. Thanks for sharing the "inside" story.
They didn't give me an option at IMFL at weigh in. Everyone I saw was getting on the scales. And the scale I got on was actually giving low readings, which isn't a problem as long as they use the same one in the med tent.

Danny Montoya said...

Cool report Jodi! Thanks!!

p.s. WE MISS YOU!!!

Brian said...

Very nice report. So, the key is to try to be in the middle. Maybe one day i'll figure that middle out.

Do they need any computer geeks out there? I can get the results to them faster then you can run them in. I'm willing to bet. :)

Wes said...

I weighed in one half pound more than when I started at SC Half Iron distance. Hydration was spot on. I'm hoping to duplicate that at Florida on November 1st. This cold weather just has my drinking pattern so thrown off though. I was doing like 2 bottles an hour during warmer weather. Yesterday, I drank 2 in four hours and still peed like 5 times. Grrrr!!!

I second the motion!! Thanks for helping out!! You ROCK :-)

Chad in the AZ Desert said...

It was really interesting to hear about things from the medical side of the equation. Thanks for the great post!

Dan said...

Great post. As an Ironman wannabe (and a relative newcomer to Triathlon) it's nice to hear first-hand stories about the consequences of not paying proper attention to your body in race conditions.

Keep the education coming!

triguyjt said...

very educational...

and most importantly very vital info.......

thanks jodi..\\
great post...

Rainmaker said...

Great post! Very interesting.

Bob Almighty said...

IM NZ I weighed 1kg more on race day than I did at weigh in, not sure if that was due to all the coke, gu2o and powerade, or the fact that I was completely soaked...