Scatter my ashes here...

Scatter my ashes here...
scatter my ashes in the desert...

Monday, July 23, 2012

Beyond Blisters: Working on a Medical Team

I just got back from my third year volunteering on the medical team at the Badwater Ultramarathon.

It's almost as much fun as running the race. Almost.

But in some ways it's even more fun because I get to watch and learn from the runners and the other medical team members.

When people ask what I do in that capacity, they often think I treat blistered feet. That is actually only a small part of what I do, we actually have foot care specialists for that and I rarely have to do any more than a minor thing involving blisters. Mostly what we treat are varying forms of heat illness, but we see a lot of other problems, too.

I am going to share some of my observations with my readers, with the intention of improving runners' and crews' future experiences at Badwater or other races in the heat.

I consider volunteering at Badwater an honor and a privilege, it certainly is not something I take for granted. I am thankful to Chris Kostman, the race director, and medical director Dr. Megan Dell, and I hope to continue to volunteer on medical at Badwater in the future.

It's a huge task that Megan takes on as medical director. She needs to make sure that all the runners and their crews are safe so that Chris can focus on his duty as race director to oversee it all. The goal is for everyone, runners, crews, and staff, to arrive at the finish line intact and keep anything from happening that endangers their safety, lives, and the future of the event.

Given the unpredictable factors: weather, judgement of the runners and their crews, the presence and behavior of several hundred people involved with the event, in addition to spectators, tourists, the general public, and highway traffic spread over 135 miles, that's a huge responsibility.

Before I go any further, I'll state that what I write here is my opinion and does not necessarily reflect the opinion of anyone else on the medical team or associated with the Badwater Ultramarathon. I'm not writing as a representative of the event, this is solely my own personal opinion from my experiences and observations.

My background

As a registered nurse, I have a certain type of training and background complemented by my 20+ years of ultramarathon experience, and two Badwater finishes, including a double road crossing of 270 miles in 2011. I have worked in critical care nursing in the past and now I'm an oncology nurse in a hospital-based clinic. Both of these nursing backgrounds have been amazingly helpful at Badwater. And I'm not even giving chemotherapy. Let's just say I'm used to treating really sick people.

I also have a background in exercise science and behavioral science from my academic training in natural resource recreation. So I'd say I'm pretty well-rounded in the various aspects of running as a recreational and human performance event. At the same time, I'm certainly not an expert on any one particular thing and I rely heavily on the judgement of the other medical staff at the race.

I see some common themes every year and those are what I'm going to discuss in this blogpost, along with how I view the runners' decisions and what I think about when I am out there on the course or seeing runners in the medical area.

What nurses do

First it might be helpful to explain what nurses do, since a lot of people don't really understand what our role is. Then you can understand how I look at my role on a medical team. Nurses act as patient advocates. We do everything possible to ensure that the patient we are caring for has the safest and best possible outcome from their treatment for a certain condition. Normally this occurs in a health care setting.

We don't diagnose or prescribe, we carry out orders from a physician when it comes to medications and medically indicated treatments, but in terms of total, holistic care of the patient, we act independently and have our own practice.

We educate patients, which is a huge part of what we do. We teach them how to manage their condition, about the medications they are taking, about the treatments or tests they undergo, what complications to look out for, and what symptoms to report to a doctor.

We look out for the safety of the patient, provide hands-on care, and help the patient access resources that will help them restore their well-being, and lead to the best outcome.

You might ask, How does that differ in a setting such as running a race under extreme conditions?

I ask, Why should Badwater be any different from the health care setting?

The answer to both of these questions is, at Badwater, not only are we paying attention to things like heat illness, we act in a preventive role and as safety educators. And safety is the number one, overarching thing we look out for.

What I do at Badwater
So when you come to me in the Badwater medical room and I weigh you, and you're down 8 pounds from your starting weight, your clothing is all full of salt, here's what I'm going to look for: First, are you making sense when you talk to me?

I'll say, Tell me how you're feeling. I'll ask questions like: Have you urinated? How often, how much, what color? How much and what kind of fluid and electrolyte replacement are you taking? Have you been eating? How's your stomach? Are you swelling anywhere?

I will take a set of vital signs if you feel "off" at all. I will help you regulate your body temperature. You'll be hot and sweaty when you come in and then you'll get cold as you sit there in the air conditioning.

We have to assess how dangerous the runner's condition is: low sodium can progress to seizures, coma, death. Dehydration by itself is usually easy to fix if it hasn't progressed too far. A cardiac condition can be life-threatening, especially in this heat.

The medical room gets jammed with people so we have to kick them out if they don't have a legitimate reason to be there. We can't listen to patient's lungs, heart, etc. with all the noise. So we have to be the bad guys sometimes and throw everyone but the runner and one crew member out. Sorry, but it's in the runners' best interest.

As long as you can keep fluids down, I will make you drink and eat something, I'll keep you there until you have to pee, if you haven't been peeing. Your kidneys and brain and gut and other organs need blood flow to keep functioning and if you're hot, all the blood has gone to your skin to keep you cool. Your body produces stress hormones that can make you retain fluid and make you puffy. After you sit there cooling down, you might start to feel better: mentally, and by eating, drinking, and urinating.

Once you're feeling better mentally, I am going to talk to you and your crew member about how to keep you out of the trouble you got in that brought you in here in the first place. And what to look for, if and when to follow up or come back to us at medical.

I'm going to explain to you what's going on with your body, electrolytes, fluids, about the blood flow, about heat stress, and why you need to stay cool. How you're more susceptible to blisters when you're not hydrating properly.

So when you're peeing, have regained some weight, and you're functioning better, plus keeping fluids down, we're going to let you go. And the time spent will more than pay for itself, because by fixing the things that slowed you down in the first place, you will perform much better.

There's a lot of education to be done in every case, both with crew and runners. They need to be more careful about intake and output. We try to pat them on the back for coming in to see us, because it was probably the best thing they could have done at that point- gives them a chance to turn things around when they're going bad.

You might ask...

Should I have a medically trained person on my Badwater crew?

Well, it's not a bad idea, but don't let that give you a false sense of security. That person also needs to have some idea of how this event differs from the setting in which they practice medicine.

I can tell you that even if a person has medical training, until they have experience working at some of these endurance events in hot weather, and know what's the reality out there, they don't really know how to treat the runners.

I say that because we get a lot of runners who have medical personnel on their crews, but they don't necessarily have experience themselves racing in the heat, or have no prior Badwater experience, and they really have no idea how to manage their runner.

I can't even tell you the number of times I've heard some version of this statement from a runner: "My wife is a doctor and she's on my crew". Well, if she's not an athlete, has no experience at endurance events in the heat, hasn't been to Badwater before, her telling me how much urine output you've put out on the average over 8 hours is not going to help me determine the integrity of your kidney function when you're catatonic and dehydrated 40 miles into the race.

"Well he's been averaging 30 cc an hour of urine output" the wife says.


This tells me nothing. He might have peed the entire 240 cc (1 cup) an hour into the race and hasn't peed since. Which ain't much of a pee. This isn't the air conditioned hospital, folks. Sorry, but 30 cc an hour at Badwater doesn't cut it.

The same parameters we use in emergency and critical care for the general unwell population in hospital settings doesn't apply here in this group of people and in 120 degree heat and physical exertion. The runner is also power breathing and power sweating out there. The runner had better be processing a lot more fluids than that through their kidneys or they're in big trouble. That means they need to be taking a lot of fluids in, and peeing a good portion of them out.

What gets runners in trouble most often is not taking the time to cool down so they can do a better job of processing fluids and calories.

What can I do to make the medical team's job easier?

1. Fill out your racer medical history form accurately, honestly, and completely. Don't omit any of the medications you take, including supplements or herbs. You would be surprised how many people in general, including endurance athletes, take things like high blood pressure medications or anti-depressants. These things can sometimes affect your ability to tolerate the heat or exercise, and we need to know about them, especially if you get into trouble out on the course. You'd also be surprised how much we find out when runners come into us, and they start talking, we learn a lot and then we go back to their medical form and they have left out a lot of important information.

2. Use us when necessary, but appropriately. We are there to ensure the runners' and crews safety. Don't occupy a medical team member's time and resources by asking for things like massages, special visits by the roadside for non-emergency situations, looking for a place to take a nap if you don't have a motel room, or in chit-chat if there are other runners around who need help.

3. Choose your crew wisely. I'll talk more about this in a later section, but it's very important. We treat a lot of crew members for heat illness and other issues out on the course.

4. Crews, when your runner is done with the race, have a blanket ready because they will cool down rapidly. After the medal ceremony and photographs at the finish line, get your runner off the mountain. The rapid ascent to 8300 feet makes altitude sickness a complicating factor with dehydration and electrolyte imbalance, sleep deprivation and exhaustion. Take them down to Lone Pine so they can begin recovering as soon as possible.

Safety on the course

This is the other thing we do when we're roving between medical stations.

I'm interested in preserving the runners' safety and the race itself. The importance of the rules becomes even more apparent when the sun starts to go down the first day. The biggest mistake I see crews making on the road is not paying attention to oncoming traffic. They park too close to the edge of the shoulder so when they open their drivers side doors, they are obstructing the roadway.

I'm going to pull over and talk to the crew if your door is open into the road even if there's only a couple of inches to spare when you pull all the way off the roadway. That's why those vans with the doors on both sides are so useful- the crew can use the passenger side to do their business in those narrow areas instead of the side facing the road.

Look both ways before you cross the street! Wear your reflective gear. Use the lights on your vehicle appropriately and according to the rules. Remember there are lots of people not associated with the race on the road. When it's dark outside, visibility is poor, even with your lights and reflective gear.

The later it gets in the race, the more tired everyone is, and it gets harder to be alert and aware of your surroundings. That's why crews need to rest and rotate shifts, and take care of themselves as well as the runner.

About crews

Since it seems like we treat almost as many crew members as we do runners, this is important to mention.

Runners, please think about your crew members when you choose them. Not only is it important for the runner to have their own head screwed on straight to run this race, but they need reliable, healthy crew members to help them do it. Physically and mentally healthy.

Not only does it affect your performace as a runner when you have crew issues, but it affects the other people on the course, runners and everyone else.

If a crew member is not physically fit to withstand 48 hours in extreme heat, sleep deprivation, heat stress, and can't manage their own stuff- meds, food, drinking, proper clothing, and they become incapacitated and do something that endangers everyone, it's not only a safety issue for the runners and everyone else, this is a threat to the future of the race.

Runners really need to be the gatekeepers when they choose their crew members. Know your crew well: do they have medical conditions that make it inadvisable for them to be out in the extreme heat? Can they adequately prepare for the conditions they will be exposed to for up to 48 hours at Badwater, with sleep deprivation to top it all off?

Let me repeat that in different words. (Because I can't emphasize this enough.)

When a runner makes poor choices as to the crew members he or she chooses for an event such as Badwater, the runner is not only endangering their own ability to finish the race safely, they are also endangering their crew members, other runners and crews, and the future of the event.

If one person becomes ill, they have just compromised the health and safety of everyone else on the crew. There are fewer people to cover the roles needed, less rest, everyone is more stressed and tired, on top of the already demanding event. Crewing for Badwater isn't like any other race. It's constant, it's intense, there is no break. The crew is heat stressed and needs to take care of themselves. As the event goes on, people become more tired, less alert, it's harder to keep on top of things like hydration, food, etc.

Do I need to say it again?

Psychological Issues

Nurses often joke about how much of what we do is psychiatric nursing. I think the same thing applies in ultramarathons.

If a runner is struggling, sometimes they just need to talk, to talk out loud through their decisions, or to see if what they're doing makes sense. And sometimes we just need to let them cry, and sit there with them as they process their disappointment, when they realize the best option is for them to quit.

I always observe how the runner is interacting with the crew. Is that an added source of stress for the runner? What I want to know is, is the crew doing anything that is hindering or endangering the runner? And if they are, can it be fixed through communication or just a little education on the spot?

Some crew members forget that the reason they are out there is to crew their runner and help them successfully and safely get to the finish line. That is what a crew is for. Being a crew member is not so you can get a training run in, or wield control over other people. We see a lot of interesting dynamics out there. Occasionally, the best thing a crew member can do is leave. See my blogposts "So ya think ya want to run badwater" and "Big Bad and Superhot".

What The Medical Team Does, and Does Not

The medical team is there to help runners and their crew members in the event of some physical problem such as dehydration or heat illness that can be turned around or fixed so the runner can continue the race, or to keep such a problem from developing into a serious or life-threatening emergency which would require full medical attention and transport to a hospital.

If someone has a minor injury that is in no way life-threatening or endangering their runner's safety, they can come in to see the Medical Team at the nearest station. Sometimes people just need to talk and we are willing to listen.

We don't do IVs. An IV is only done when medically necessary and it always means the racer will be disqualified. If you're of the mindset of some of the triathlons and other races out there that provide IV rehydration to participants at the finish line, you're in the wrong place. Placing an IV, especially in non-sterile conditions such as a race medical tent, increases the risk of infection or bacteremia from contamination.

If the race is over and you're feeling like you need IV rehydration, there's always the emergency room of the local hospital. I don't encourage this unless the runner is unable to keep food and fluids down. The best thing to do is to rehydrate and recover by drinking, eating, and resting.

I'm not a shrink. Roadside psychiatry is not really one of the things I do. If anyone has a concern, they should feel free to come to one of the medical stations, but unless someone is in danger, we generally don't make roadside visits for non-medical issues like massages, pep talks, and hand-holding.

What's it like working on the medical team?

It's a good mix of physicians, nurses, first responders, an exercise physiologist, and foot care experts. (I think we could use a clinical psychologist too.) We're all professionals who are committed to our areas of expertise in our real jobs, and the combined level of education, experience, and skills make this particular bunch of people top notch.

We don't get a lot of sleep. We share duties like covering different stations, the finish line (where we all freeze), getting sleep and naps, getting food or short run breaks. We have to do inventory and keep organized for all the equipment year after year, making sure supplies don't expire, having enough of certain items and discarding what we really don't need. Also, we need to be anticipating runners' needs at each station and being ready for that.

In a successful year like this one, there were no IVs, almost all the runners we saw were able to go back out on the course and finish with oral fluid and electrolyte replacement.

During the post-race party, we always get runners who come up and thank us for our care. We were able to help them turn the problem around, get them back on the road, to a successful finish. Sometimes they amaze us, someone who looked like death coming in to Stovepipe Wells spends a couple of hours cooling off and rehydrating, and they blast off to the finish line. Nothing makes us happier than to see the runners we treated 90 miles down the road cross the finish line with a big smile on their faces and their crews faces too.

It's really fun, we're a big bunch of nerdy people, and we all have a sick sense of humor. Yes, almost as much fun as running the race.

As you can see, we do a lot more than blisters. And we wouldn't come back year after year if we didn't love it.

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