Ironman

[Dominic]

Not sure famous is the right word. And as for selling yourself ' it''s only 20 miles from Manchester'

[nick de meyer]

Exercise Associated Hyponatremia

I've been asked to circulate this for anyone taking part in an Ironman or other long distance event

Last weekend I was lucky enough to take part in the London to Paris bike ride in aid of the Laureus Sport for Good Foundation. It was a 250 mile trip over 3 days, and with the sun beating down everyone was cautious of staying hydrated, because most of the horror stories we hear are to do with not drinking enough, particularly during long distance events. As one of my big goals is to complete an ironman, I was really keen to speak to one of the organisers of the event, Kate Roberts, who I clocked sporting an Ironman t-shirt on the first day of the ride. What I heard about her experience shocked me and I felt it was important to share this with other endurance enthusiasts, because whilst dehydration is a major concern, it's essential to know that caution MUST be exercised both ways.

Many thanks to Kate for allowing me to share her story....

To be the fittest and then the sickest you’ve ever been in less than 15 hours is not a good place to be. It is now two months since the Ironman triathlon in Zurich on 2 July 2006 (Swim 2.4 miles / Bike 112 miles / Run 26.2 miles) but although I finished it in 14 hours and 56 minutes (and have the T-shirt) the success of that achievement was overshadowed by ending the day in the University Hospital in Zurich in a coma suffering a tonic clonic seizure due to a sodium level of 111 mEq/L.

Hyponatremia results from an abnormally low concentration of sodium in blood plasma – the normal range being 136-142 mEq/L; severe hyponatremia is recognised as 120 or below. I was lucky not to suffer the fate of others who have died from hyponatraemic encephalopathy (swelling of the brain caused by severely reduced blood sodium). Hyponatremia led to the death of a female runner during the 2002 Boston marathon.

Now that I have the mental and physical strength to accept what happened and move on, I feel almost a duty in highlighting the risks to others who take part in endurance events. In a way, my consolation is that if I can prevent someone else going through the same experience or worse then something positive will have come from it.

Hyponatramia is also known as “water intoxication” which is a simplification of the condition and it does not necessarily result from just drinking too much water. The single most important factor associated with hyponatremia is excessive consumption of fluids which can include isotonic drinks. Reports are that hyponatremia has become increasingly common with the increasing participation of recreational athletes in endurance events.

As I found out, hyponatremia can be extremely serious, with symptoms ranging from nausea, confusion, uncoordination, disorientation, dizziness and weakness all the way to grand-mal seizures and life-threatening comas. So how did I end up in that state?

When you have been training 5 or 6 days a week for six months and set yourself a target you don’t give up easily. The problem was I did not have an appreciation of the risk factors involved. Recognised risk factors include low body weight; female sex; 4 hours exercise duration, slow running or performance pace, race inexperience, excessive drinking behaviour, high availability of drinking fluids, extreme hot or cold environmental conditions. Nor did I have an awareness of the symptoms.

When I entered Lake Zurich at 7 am that morning with a mass start of 1900 other competitors (of which approximately 1500 would finish) I felt ready. I’d given serious consideration to the whole undertaking; the training had gone well, I’d remembered the sun cream (easily forgotten at 4.30 am), I’d even calculated the calories I’d need each hour and had neat stashes of sports bars, gels and the odd peanut butter & marmite sandwich on my bike. I’d worn my kit in (no new shoes on race day), I’d stapled my race number securely to my elastic race belt and I’d told myself not to get dehydrated.

The swim was the usual open water washing machine of arms and legs with no way to avoid the chaos of so many wetsuit clad strangers unavoidably kicking their way through, unwillingly linking arms, clipping heads and fighting for open water, yet madly attempting to follow the same course round the lake. The sky was blue, the day heating up into what was to become the hottest day of the year so far. I was already sweating in my wetsuit and swallowing water.

Emerging from the lake after an hour and quarter I felt elated; over the worst part, I told myself. I passed through transition with its inevitable comedy moment of hopping round on one leg, wetsuit resolutely gripping on to your ankles when not even ‘Brave Soldier’ lubricant can really help. My trusty steed awaited, over 1,200 miles covered in training since January.

There’s a certain freedom you get from cycling. The elation of reaching the top of a hill, the exhilaration of the descent, the passing of the miles, but when you do a bike course 3 times with a beast called ‘Heartbreak Hill’ for an ascent is it any wonder you feel a little disorientated? Besides it was now soaring up to 36 degrees C. I was worried I’d dehydrate and I’d had a mild upset stomach for the couple of days leading up to race day. Conscientiously I drank at most of the aid stations, ensuring I always had a bottle of sports drink and water on the go. Water was needed to wash down sports bars and gels. The hours went by. My strategy was to go at a steady pace and save my legs for the run. I had plenty of time to sit in the saddle and drink, watch the scenery, miss a marshal on a small turn off, cycle an extra 4 miles (because 112 miles simply isn’t quite far enough) and not appreciate what was happening to me.

After 7.5 hours on the bike I was ready for transition. A quick visit to the loo and an even quicker deposit of contents made me concerned as diarrhea leads to dehydration does it not? "Must keep up the fluid intake", I thought.

The run was 4 laps of a circuitous route up and down the lake side. There were 5 aid stations on the route. “Good”, I thought, plenty of scope to drink and not get dehydrated. The first circuit was alright as I joined up with one of the guys from the club who was on his second lap and ran the pace I’d planned. I guess it was after that circuit that the problems started.

I couldn’t get my heart rate higher than 128 bpm and yet I'd been aiming to run at 138 bpm. Somehow I was sluggish but understandably put it down to having been on the go for 10 hours or so. Anyhow, the crowds were great and with my Mum and friends at various places around the course I had the encouragement I needed to keep going. It was very hot, I was sweating and stopping for more worrying loo stops on each circuit but at least I had access to fluid so I’d be fine…

At about 20 miles I started to lose it. I went to the loo (again) and on coming out of the cubicle I couldn’t orientate myself. I wasn’t sure which way to go. I knew this was bad but not how bad. I knew I was a bit confused, disorientated, nauseous but, hey, I’d been out for about 13 or 14 hours by this point so wasn’t that how you’d expect to feel? The problem was this was a one way course of 4 loops and I’d already been round it 3 times. Surely I’m not that bad at directions? I asked someone which way to run. My words were slurred. I repeated myself and they pointed one way. I went that way. Walking now, I tried to remain positive. I must be dehydrated I thought. What else could it possibly be? I’ll have some more flat coke which I’d heard was good to drink towards the end of the run.

At one point I felt panicky. Maybe I can’t do this. Maybe I can’t finish. The fighting instinct kicked in. There was no way after the swim, bike and 20 out of 26 miles or so I was going to stop. Not after all the training, all the long weekends on the bike, the missed socials, the early morning swims, the cold baths after long runs. No, not after everything I’d worked towards together with friends who were out there surely going though the same mental anguish as me. Besides, how could I give up when all I had to do was put one foot in front of the other and I’d be alright. Time became irrelevant, my thirst became insatiable. I lost all idea of how long I’d been on the go. All aspirations for a sub 14 hour time melted away and this was now just a matter of mind over body to reach the end; the summit. I now know what summit fever feels like.

So that was it. “A long day out with a picnic” I’d told friends (who were less inclined to accept that doing an Ironman in Switzerland fell in to the category of a summer holiday).

I crossed the line after 14 hours and 56 minutes. The sound of the crowd in the stands cheering my staggered run up the red carpeted funnel where I ran smiling underneath the digital clock with my name on the screen, my hearing muffled, my head throbbing, my sense of needing help now heightened.

“I think I need a drip” were my first words to my friend Ruth who, having completed the course in an amazing 12 hours 12 minutes, was taking photos of those of us without wings.

I don’t remember much else about that night. Tunnel vision set in, my hearing became more muffled, I felt I had “messed up” and felt the world slipping away. I was agitated; I begged my poor mother not to let me go to sleep and told her I was sorry.

I was unconscious by the time the ambulance took me to the hospital and in a coma for two days. The ITU staff hadn’t had a case of hyponatremia before and looked up how to treat it on the internet. According to my mother they were amazing. I have them to thank for looking after me (especially during the seizure) preventing a brain herniation (the CT scan showed water round the brain but not yet in it) and raising my sodium levels slowly enough so I didn’t suffer any of the potential side effects including an array of neurological problems.

When I woke up I’d lost some of my memory. I had absolutely no idea where I worked or how to use my mobile phone. Bit by bit these things and the events of the lead up to the race and the race itself came back. Looking at photos now is helping to fill in gaps I didn’t realise were there. I was in hospital a further 3 days whilst they sorted out the rhabdomyolysis (break down of muscle fibres toxic to the kidneys) and restored me to something of my former self. My psychological state has taken longer to heal with affected levels of confidence, self esteem, anxiety and serotonin, not to mention a nightmare which left me hyperventilating, but I’m on track and have been supported all the way by friends, family and colleagues to whom I am extremely grateful.

The fact that I carried a European Health Card (the old E111) has helped avoid financial repercussions as this paid for about 95 % of the medical treatment. It’s worth logging on to www.dh.gov.uk under Health Advice for Travelers and spending a few minutes organising cover.

As I mentioned already, I do feel an obligation to flag up the risks of hyponatremia to others who take part in endurance events. The motivation behind recounting this personal experience is to highlight awareness of the effect of excessive consumption of fluid and the need to consider nuitritional requirements including whether salt tablets are appropriate.

On a very positive note, I raised over £2,000 for Sight Savers International, a charity which, working with its partners in 2005, helped to treat over 15.7 million people for potentially blinding conditions and restore the sight to 233,203 people.

I was and am lucky to be here and however trite it may sound the experience has made me reflect on the important things in life. Do circulate this to anyone you may feel would benefit from knowing about exercise associated hyponatremia and help me make a positive out of a negative.



Kate Roberts