Monday, May 21, 2007

Dehydration and other ultrarunning hazards



I had the pleasure of running the Bishop High Sierra 50 Miler Saturday. I was entirely impressed at how beautifully scenic this race was! Marie did a superb job with all the race details and yet still had seemingly endless energy left for extra special caring touches for her runners...including me....several times.

This was to be a training run for me -my first run of the year in the heat. It was also my longest ultra in 2 years and would be - for better or worse - my longest training run before Badwater. So, I was there to enjoy, finish, and especially recover well enough to get back to Death Valley this coming weekend for another long weekend of training in the heat.

I didn't know anything about the Bishop course except that it looked beautiful from a couple of pictures I looked at. I just never had time to review the course or anything. I only knew it was going to be a spectacular run in the Sierras and that it was going to include elevation (hence the Bishop HIGH Sierra name!), and that it was going to be enjoyable.


I ran easy according to how I felt. I only found myself pushing just a little when I was running with the amazing Anita Fromm who is also running Badwater this year. She is faster than me, and I found our stimulating trail conversation was leaving me a bit winded. So, I let her go on. I ran my own race, and even purposefully slowed to stay with others on some of the uphills. I felt great. It was very warm (by WA standards) and there was no humidity. I drank and ate according to how I felt, paying a little more attention to getting in more calories than usual. The aid station pancakes and bean and cheese casadias all went down easy and were great fuelers for the long miles.

I didn't slow but rather felt even better as I approached 35 miles. I did, however, have a couple episodes of minor cramping in my feet, and a twitch in my left quad, but I drank and took some salt at the aid station, stood under the light misters to cool, and all was good. By this time, I had stopped to pee three times. The first time I peed as usual, though not much. The other two times I stopped because I felt like I really had to go, but when I tried, I couldn't. When I tried to go again, I was shocked by the dramatic "blood" in the small amount of urine I was able to produce.

Thing is, I was feeling ok, and had in fact, just run several downhill miles with no problems (other than the occasional minor cramping), so I was taken by surprise that I had what I knew was not really hematuria (blood in the urine) but myoglobinuria (a sign of muscle breakdown products in my system) and rhabdomyolysis - the very topic I stayed up all night the night before the race to study and prepare as part of my presentation at the American College of Sports Medicine.

At that point at about 42 miles, I became very worried. I did a "systems review" and ran through all my bodily checks. My calf, which was strained a week prior - and could have increased my risk of developing rhabdo during the race - felt absolutely fine. I had absolutely NO pain or tenderness in the calf. My muscles overall felt fine, not overly fatigued, though the cramping was sporadic and suggested dehydration and/or hyponatremia. My fingers and wrists were as puffy as they often get in the heat and they had been this way since about an hour into the race. A sign of low salt? Too much salt? Maybe neither? My "faculties" seemed to be working. I didn't feel at all "out of it" nor did I have any other general problems. My gut felt fine. No nausea; I was eating well. My mouth was moist; I could work up a spit if I had to. I wasn't thirsty; I didn't crave salt. I asked myself again later if I was thirsty and I wasn't. I drank anyway.


(picture courtesy of Ben Jones)

My ankle was fine, though I had some tweaks of anterior tibialis tenderness about half-way through the run, but it felt fine then. I had enormous quanitities of salt caked all over my body. Even my kneecaps were crusted in salt! I was not at all heat trained and I knew that...but it was also not all that hot to me. Sure, the heat slowed me down and I was all up for that, but I didn't feel overheated. Of course, heat is another risk factor for rhabdomyolysis, so that was a concern for me.

I drank some more and took some salt. I chose to walk/run very easy the last 8 miles to the finish. I stumbled once on a rock but did not fall. I continued to cramp on occasion and had a pretty bad cramp in the left quad after running up a hill with sweet Lisa Henson who had caught back up to me at that point.

When I finished (in about 11:42), I tried to pee again, and again...large "blood." I also felt urgency, like I had to pee but couldn't. I immediately grabbed a Sprite and then gratefully accepted a liter of Gatorade from Kay B and started working on that. I talked to Marie and asked her if IV's were available. I knew I needed to get a few liters of fluid into me to protect my kidneys. They were not at all happy. I thought I could go back to the hotel and drink lots of fluids, which certainly might have worked, but I was alone and felt it was safer to seek some help rather than to resort to my usual "physician treat thyself" techniques. Sweet Marie directed me to Nurse Tracy Aspel, Clinical Nurse Manager of the Rural Health Clinic in Bishop who was volunteering at the race. She was my angel and I owe my quick recovery to her. She was kindness personified, I tell you! Nothing short of the best caregiver a runner could ever hope to have.

She drove me to her clinic in Bishop. I hopped on a scale. I was 93.5 pounds, down nearly 5% of my weight (and this was after about 1-1/2 liters of fluid since the finish). I continued to cramp. She gave me 2 liters of 0.9 normal saline. My BP was 106/84 (low for me without my antihypertensives, which I don't like to take when I run) and heart rate was 82 (pretty high). Everything suggested a pretty good level of dehydration. I became cold with shaking rigors during the IV (common) and she gave me a blanket. She warmed the second bag and place it on my chest while the first bag ran in. Oooh! Did that ever feel good! And then I received the 2nd bag of warm fluids. And let me tell you, there is nothing more soothing than WARM fluids running into your arm and body. Mmmm!

I felt significantly better after the fluids. No more cramps. I could stand and laugh and I just felt MUCH better. We decided to get "academic" and did a urinalysis since I was able to produce some urine. It was still reddish-brown with specific gravity 1.010, ph 6, no WBC, no nitrates, protein 1+ (30), no glucose or ketones, urobili normal, large amount of blood. When looking for rhabdo, however, blood is positive on heme testing, but the microscopic exam shows no red blood cells, which means that the "blood" is from myoglobin released from the muscles during breakdown. As expected, the microscopic exam was negative. I had dehydration and myoglobinuria from rhabdomyolysis.

My angel deemed me well enough to go and I thanked her like 150 times. I was amazed at how much better I felt. I drove myself back to the race to let Marie know I was fine. Even though it was then 8:15 pm, 15 minutes after the official 14 hours cutoff, there was still a runner making his way to the finish line. Good for him! I talked to Marie, who was still ticking after many many hours of hard work and service to her runners. She still had enough compassion to hug me and wish me well. She said there was at least one other person who said he was "peeing blood" for many hours. He was apparently otherwise well and was instructed to drink and seek help if he needed. (In talking with other runners later, I found out that several other of my friends had similar problems to lesser degrees...it was HOT out there!)

I talked to Tim Kj at the finish. He ran a comfortable race, slow enough to protect his knee and not hurt it more before his arthroscopic surgery this week. He looked good. I found my drop bag, which I never needed due to the highest quality aid stations and volunteers who took care of everything, and I headed back to the hotel and to get some dinner.

Well, in Bishop at 9pm, everything is pretty much closed so dinner was quite uneventful. I talked to Robert A for a long time at the hotel and then started my deliberate rehydration, needing still to increase my weight ABOVE my normal weight to ensure diuresis. I expected to be up relieving myself throughout the night.

To my surprise, after I finally went to bed (now up for nearly 2 days straight), I slept well and never needed to wake to pee. I woke early to make my long drive back to Reno and was surprised I was still dehydrated with concentrated reddish urine! So, I packed up and picked up 3 more liters of Gatorade and I made my long and scenic drive to the airport...stopping many times along the way.

I kept waiting for the muscle soreness and pain, but it never happened. The drive was fine, if not pleasant, and the trek through the airport was similarly sore-free. It was bizaare. I expected to have at least some soreness, but had none. I thought that maybe it would just come on later (DOMS) and the airplane would start the swelling in my legs that always occurs. But no...

So, I figured that today would be the final test. I completely expected to wake with profound muscle soreness...or at least a little sore. But no, I have almost no soreness. I could easily run 10 miles today if I wanted, though that would be a foolish thing to do! I made it through a long day at work today with the accumulation of some mild swelling but no soreness. I continued to hydrate and my urine became nearly clear.

So, being in the healthcare field and with access to resources, I decided to check my kidney function and CPK labs. After all, if there are problems there, I need to reconsider my Death Valley training weekend. So, at lunchtime, I went to the lab and ordered a few things. Here are my results from today (about 40 hours after completing the race):

Sodium 140 (135-145)
Potassium 3.8 (3.5-5.3)
Glucose 59 (65-99) LOW
BUN 10 (7-23)
Creatinine 1.0 (0.6-1.2)
BUN/Cr ratio 10 (7-24)
CK 381 (20-200) HIGH
TSH 2.25 (0.4-5.0)

So, everything is normal except for the "high" CK of 381. That's of no concern to me and indicates it wasn't all that high to start (since it tends to peak about 24-36 hours post exercise). I have no idea why the glucose was low since I had eaten a bite for lunch about 30 minutes prior and certainly did not feel hypoglycemic. So, I'll ignore that. The kidneys are fine! The electrolytes are fine, and the TSH (thrown in for curiosity's sake) is also fine.

So, here's my Assessment:

Diagnosis: 1) Dehydration, 2) Myoglobinuria from Rhabdomyolysis

I was not heat acclimated. It was very hot - for me. 95 degrees with very little humidity. The wind further dehydrated me. I am out of touch with my body since I haven't run longer ultras for 2 years. I may have been hyponatremic too (tons of salt loss), but that's of little concern since I was not symptomatic from that. The cramping was from dehydration. I even had some subtle cramping in my jaw! That was just so weird. The swelling in my fingers was just there. It's not a reliable sign of anything. It can occur even with moderate symptomatic dehydration, which is what I had. Thirst was not a reliable indicator of hydration status. I was not thirsty. The rhabdo was likely "normal" and not excessive for a 50 mile race. It was just that the rhabdo became a problem only because I was dehydrated. That was my problem and that is why maintaining proper hydration during ultras is so important. These are not 5k's, 10k's or marathons; these are long and difficult ultras often in the heat and - in this case - at altitude, and muscle breakdown is inevitable. Keeping fluids flowing in and out is important. It's easy for me to overhydrate, but I must not dehydrate either! (Note, I normally have a LOW CPK finish line level because I just don't push myself that hard. My Western States finish line CPK in 2005 was like 5,500 when average was 17,000.)

So, that's the whole story. Uneventful, which is what I wanted! The "eventfulness" is only in the fact that the Bishop High Sierra 50 is a wonderful race. It was the perfect choice for me for training and also to see so many of my friends. It ranks among the best for me so far.

I had a light massage today to help with the minor swelling and I STILL am waiting for the soreness! I am now convinced that it's not gonna happen. I'm ok; I am recovered from the dehydration and therefore am at no risk whatsoever from the possible adverse effects of the mild rhabdo.

I'm ready for Death Valley!!

Thank you so much to all my friends for the caring phone calls and emails.
(pic courtesy of Ben Jones: Tropical John who ran the 50k and Lisa Henson who ran a great time for the 50-miler)

I didn't realize how fast word gets around when you are sick after a race! At first, I was a little embarrassed. I should know about these things, right? Well, right, I should know about them, and I do, but I'm an ultrarunner like you and you, and run under the same adverse conditions. I do my best and still make mistakes. I love to learn...and I guess mistakes are my way of learning things first hand. :)

Oh, and a link to Dr. Ben Jones's pictures from the race is HERE. Thanks, Ben!

19 comments:

olga said...

Lisa, so glad you are fine and kicking!!! What a post, like reading a med textbook:) Good run no matter what, you got your goals down and survived the heat, the altitude, the distance and the ankle. Ready and counting now!

Bob Gentile said...

you had me at "HELLO" umm I mean "rhabdomyolysis" - nothing like a sexy, smart ultra runner to get me moving in the morning-lol

SO glad ur feeling better hun & have a pretty good feel of what happened...

Death Valley training will be helpful for u to focus more on ur fluids... looks like the climate conditions from Bishop snuck up on ya :-(

Have a great recovery week!!

Eudemus said...

What a great post. While each of us is definitely an "experiment of one", few of us are qualified to perform the sort of scientific analysis to learn from that experiment on such a deep level. Thanks for sharing all of your expertise. By the way, what do you think is responsible for the lack of expected soreness? Could it be the fluids you received post race? Anyway, good luck with Badwater training!

Marshall Ulrich said...

Lisa, glad to hear you got some fluids in you. I look forward to hanging out with you in the big valley. Take care of yourself, I know you will.

KendraBo said...

I'm so glad you're okay! Better than okay, even! So you got your "bad water" experience out of the way before Badwater. Sorry, that was bad. >:) Glad you're back safe 'n sound, dear.

George said...

Lisa,
I'm going to have to read this post over another dozen times to make sure it sinks in. There are SO many variables when running long and I have so few brain cells left to process all of the possibilities let alone REMEMBER them at mile 50! You didn't mention anything about ADH though. Could that have helped put you over the "dehydration edge" too?
(~: George

kelly said...

Lisa, great race report and I am so glad that you are recovering so nicely. I'm glad that the rhabdo didn't get out of hand. Take it easy and you will be ready and strong for Badwater!

Backofpack said...

Lisa,
I've never read a race report quite like yours! I'm glad you are okay and not sore at all. That's awesome!

So...as Eric's crew at WS and a non-medical person as well...I'm not quite sure what I got from your report. I guess every person is different, so maybe it doesn't really cross over. And there will be medical people looking at all that stuff and asking the right questions...right?

Lisa B said...

Hi Steve - Not sure why I never got sore. Muscle soreness is a symptoms of Rhabdo. I can only guess that the Rhabdo really wasn't all that bad, but it LOOKED bad (urine color) because of the dehydration. I do think the IV's helped though.

Hi Marshall - I'm looking forward to seeing you too. Kari and I were talking about how "easy" you are to crew at Badwater. She had some great stories to tell (doesn't she always??). I just love her! See you there!

Kendra - you are too funny! Yes, no more bad water. And bring on Badwater!

George - I may or may not have had some ADH action. I don't think so, but in any case, it was definitely not the main problem. I was dehydrated, not abnormally retaining fluids.

Thanks, Kelly. Rhabdo is very very common at ultras. It's just that sometimes it causes problems. Dehydration puts us at risk for problems with the kidneys. As you know, at its worse, it can cause acute renal failure and require dialysis for treatment. That can happen if there is not adequate hydration.
...but you know all that. Hope your training for WS is going well. I will see you there. I am pacing. Whew, just 4 weeks away!

Michelle - The medical personnel at WS are among the best. Eric will be in good hands with them and you! Just keep his weight relatively level, no more than decreased by 2%, for optimal hydration. He's an experienced runner; he should be fine!

Lisa B said...

and thanks Olga and Bob, my biggest cheerleaders! :)

timkj said...

I wonder if your lack of sleep the night before could have added to your condition. I don't remember being sore at BW 2005 when I dropped from Rhabdo. I felt pretty good(except for the blisters). Glad your feeling better.

Viper said...

Lisa,

This post scared me silly. I ran this race and I know more about nuclear science than I do about the things you mentioned. I guess if I'm going to continue, I had better pay attention.

My post-race consisted of being mostly incoherent. Too chicken to do IVs and my pee was like syrup. No cramping, a lot of soreness, and I can just imagine my labs would have looked like an ER situation.

Ignorance was bliss. My kidneys likely hate me now.

Lisa B said...

Viper, the more I learn the more I realize that ultrarunning is not all that great for our bodies. Sorry, everybody, but it falls in the category of "extreme." But that's what we all LOVE about ultras too - how extreme they are. And that's what I love about them too.

One of these days I should make a list of all the lab abnormalities we see from ultras. (One of the reasons I tested my thyroid is that post-ultra it can't be screwed up, as can many other hormones...testoterone included.) I'm amazed at how much this kind of stress can screw up the body. The good news is that it all comes back to normal. And also, to a large extent, the body adapts, and adapts very well considering the enormity of what we are doing.

I could also, of course, make a long list of the benefits of ultrarunning...but almost everything on that list would be mental or psychological or social benefits, not physical. And those are the reasons I run ultras.

Staying safe is paramount. We all have families and friends that love and need us.

Being sore afterwards is "normal," and the body does adapts with time. The kidneys need to stay flushed and fluids are critical in the heat and for our recovery. Just keep the kidneys flushing and you'll be fine. Eat salty foods or drink gatorade or pedialyte or similar with post-race rehydration.

...Them my thoughts on the "benefits" of ultrarunning. :)

Lisa B said...

Tim - I think you situation was similar to mine in that the rhabdo was not all that severe but that your kidneys weren't flushing out the fluids. There was dehydration and probably also an element of ADH (the anti-diuretic hormone released during stress and heat that tells the kidneys to hold fluids and not to pee).

Ken Corathers said...

Lisa,
I was so relieved to read your blog. The Bishop 50k was my first ultra and experienced all the symptoms you described. I asked a couple of experienced runners at the finish and they hadn't heard of the symptoms I was having. I used to work as a wildland firefighter and worked in lots of extreme heat and shifts as long as 36 hours w/o ever having those symptoms. The only thing I could think of was that I drank too much Heed and not enough water during the event (water tasted so swampy). I still don't understand this rhabdo thing, but maybe I can find a local sports med doc to explain how to avoid it in the future. Thanks for the post

Jim Browning said...

Lisa,

I have a client (I am an ART Provider) who is an ultra-marathoner, and I am concerned that she is in a chronic state of dehydration.

She drinks hardly any fluids, and when she does, she retains the fluid.

Where would be a good place for her start getting this checked out?

Thanks!

Stephen Mader said...

Congratulations on Badwater - Unreal effort.

Alex said...

thanks for the great race report. I am actually going to try my second 50 mielr this year, first was DNF and i enjoyed your report

Alex said...

thank you very much for the report. I am actually going for my 2nd 50 miler at bishop, first one i DNF at the AR50, so i appreciate the detail and the report. thank you so much and i hope you are still running the trails well