LA Marathon Clinician Lessons

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Nurses Edition Commentary

Mizuho Morrison, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Matt S. -

For more info on hydration status in athletes check out "Waterlogged:
The Serious Problem of Overhydration in Endurance Sports" by Dr Tim Noakes. He really challenges some myths about hydration before, during and after events. He also discusses Exercise-Associated Hyponatremia, and how ACSM's guidelines were heavily influenced by sports drink companies (well, mostly Gatorade).

Alexander M. -

Not to be too much of a snob, but 26.2 miles over a few hours on well paved/ marked surfaces with regularly spaced aid stations hardly qualifies as an 'endurance sport'. Those folks slogging out 50 (or even 100) miles on trails with little support seems more fitting of the 'endurance athlete' title.
A friend out of shape daughter got rhabdo from a spin class - point is people can get athletic injuries at any level.

Aaron R. -

Great overall review, however I do have two concerns. First, obviously ABCs come first. However, having the next step involve checking the core temperature can be inaccurate and misleading. Individuals with significant exertion can have an increased core temp >40 without symptomatology, so hyperthermia dose not equal heat stroke. All of the other causes of athlete collapse can still be present. Also, most generic thermometers are less accurate or completely inaccurate at extremes of temperature and meant to accurately detect fever, not hypothermia. This means you cannot rely on the thermometer to accurately diagnose hypothermia either. Taking in the entire clinical picture and initiating evacuation should be the priority. That being said, cooling a warm person and warming a cool person is unlikely to lead to adverse outcomes, unless the diagnostic process ends based on a measured temperature.
Secondly, IV fluids are not benign. Some degree of SIADH is present during intense exercise. As opposed to hypovolemic hyponatremia, in which ADH turns off with vascular filling, the SIADH seen in exertion continues. Administration of fluid volume will lead to continued production of hyperosmolar urine and retention of free water, which can worsen exertional hyponatremia. In reality, there are very few instances when IV fluids are required, and caution should be used. The vast majority of exercise associated issues can be fixed by oral rehydration with an appropriate solution.
Dr. Noakes (referenced above by Matt) as well as several others, including Dr Matthew Hoffman, Dr Grant Lipman, Dr. Jeremy Joslin, and others, have published extensively on medical issues in endurance athletes and are great resources in regards to these topics.

Elizabeth E., RN -

Hey all- just wanted to post a little something as this past year I had the opportunity to be the lead RN in the ICU tent at the 2014 Chicago marathon and work alongside my one of my favorite docs Sanjeev Malik. There was a few comments made about meds and tests available and we really had a sweet set-up in the Windy City. Most, if not all of our patients feel into 2 basic categories- the altered runner or the chest pain runner. We had a great crew of docs, ICU nurses, Red Cross volunteers and marathon IT folks who were really able to turn this free standing tent into a tiny urgent care. We checked folks in, performed EKGs, had point of care testing for glucose and basic chem panels and if someone was altered with confirmed labs, we had hypertonic saline, normal saline, benzos, zofran, aspirin and a handful of other drugs. The only thing we were in short suppy of was lube! With everyone getting a rectal temp this definitely made things interesting for us. All in all, a great experience and a great team- we had a blast!

Darryl J. M. -

Tough topic. An urban marathon is quite different than a backcountry ultramarathon; good points brought up. Diagnosing exercise associated hyponatremia clinically is impossible-you need a point of care device. If a patient is seizing from hyponatremia, I would not recommend benzodiazepines first; hypertonic or even normal saline would be better initially, then if the patient has a seizure disorder on top, that can be treated as usual. Benzos don't really stop hyponatremic seizures.
As far as stripping a person down in the middle of the road or trail to insert a rectal thermometer in a nice concretion of poop would be fraught with temperature inaccuracies, and it would be best to simply treat the patient first, and opt for a measurement as Aaron above stated. Get that patient out of the elements first, and remember, with potentially severe ATP depletion, hypothermia could actually set in. Thanks for the podcast.

Joseph M. -

hi Oma

Adam D. -

I thought this was a great review, especially as I'm trying to recall all of the physiology of the injured/sick runner before the Boston Marathon next week.
I think importantly to recall is these folks are mostly healthy and incredibly happy to receive any help and care. This is a great chance to refresh your medical spirit that some times can be dragged down by too many night shifts.
Hearing about the months of work and planning that go into the Marathon, I am grateful that there are dedicated folks making these events run smoothly and the small hospital that is set up at the finish line in Boston every marathon day morning reminds me that a few dedicated people can really do great work!

Mark T. -

It was coincidentally cool having this segment play between miles 35 and 38 of my "middle distance" running race yesterday. Having run 10 to 15 of these "endurance athlet(ic)" events (mostly of the kind and degree to which Xander refers above) each year for the past 12 years, I have had plenty of opportunity to observe and/or experience first-hand many of these issue raised (unfortunately including when I first got into it, receiving gross neglect in an ED after an all day event when temps hit the upper 90s, but that's another story....good thing I never seized, or maybe I'd be dead now.)

Provoked a lot of thought and questions, too many to address now. Indeed lots of myths and assumptions abound, and there is a lot that we simply do not know.
Thus I am really appreciate your including this segment,as I am grateful for the work researchers like Noakes, Hoffman, and other have put in.

For now, let me just mention that simply wearing tech fabric shirts rather than cotton will not necessarily protect you from bloody nipples. Tape. Save the lube for the crotch.

The other thing I'll do here is send you fan mail. I usually listen to each EM:RAP podcast all in one stretch while doing a long training run. While I get to enjoy great scenery during these runs, I feel a little guilty indulging without some intellectual improvement (and too often lose my NPR radio signal). I feel like not only am I getting in my miles and elevation change, but also (hopefully) becoming at least a little smarter and better prepared for my next shift. Once a month.

The race yesterday involved a repeated 4.4 mile stretch around a lake in southeast San Francisco. Not the most visually stimulating; maybe why I've avoided it for five years, opting for my usual trail events. The March podcast kept me awake and moving from mile 15 to 48. (After which I gladly switched to music to finish out the final 14.) Didn't make me any faster, but I was definitely less tortured. I'm pretty sure I absorbed some of what you guys were trying to teach me!

So, thank you so much for all your work. Love you guys!

Skins, MD -

The comment in the lecture that "80% of Marathon runners will vomit by the end of the race" seems to be exaggerated.

Jessica R. -

Some thoughts (belatedly; yes, I'm that person who is shamefully behind in my audio CME). Having run about 20 marathons myself, as well as trail races up to 60 miles and being on the other side of it, on the first real hot day of the year running my first ultra and becoming dehydrated to the point of delirium and rhabdomyolysis and a 3 day hospital stay (yes I finished the race, although with some help as I didn't really know where I was going any more). Also I've worked the medical tent at a local marathon with about 3000 participants (full and relay) for 2 years. (I don't run it anymore, too crowded and pavement-y). Even now that I do ultras, running a marathon FAST is definitely an endurance sport. Jogging it's one thing but approaching 3 hours is gritty for some of us.
We see a lot of dizziness/nausea, muscle cramps, heat exhaustion. The sickest patients are brought to us by EMS having been "found down" and almost all are heat stroke. Out protocol is: Found down,ABCs, monitors, IV access, continuous rectal temp probe. If AMS and rectal T>104, ice water immersion with T(R) transduced. When T(R)=102, patient removed from ice bath to avoid overcooling and wet clothing removed, patient dried and covered. While in the ice bath, ISTAT chems obtained. If Na+ normal, cool saline infusion, bolus if hypotensive. We have BZs for shivering or agitation in the ice bath. We also have EKG, ASA, RSI kit and monitor/defibrillator at the main and satellite (halfway point) tents. All heat stroke cases are transported after cooling to 102.
There is one doc at the satellite tent (me this year) and at least half a dozen at the main tent (we have ICU docs, a CT surgeon, and residents, I was the only ED doc this year that I know of. It is all volunteer). This year it wasn't very warm (60, overcast) but I did get one heatstroke (at the 14 mile mark!) one with palpitations and one with chest pain. I have not seen any hyponatremia in 2 years not heard about any significant cases. The sickest one I had was an older fellow with a temp of 108.7 (!!) he was gray with cool clammy skin and I was fervently praying he would not code in the ice bath. He ended up surviving with intact neuro function (although has not run another marathon AFAIK).
This is seriously the most fun I have all year doing medicine. I plan to do it every year.

Jessica R. -

P.S. Skins, I've run probably close to 20 marathons and have never vomited. Came close during a couple ultras.
Xander, blisters, cramps, dizziness, nausea, chafing, emergent bowel evacuations--- all "normal" for an ultra, right? How about a nasal bone fracture? (Vermont 50, 2014--did NOT improve my finishing time.)

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