Kitima, unfortunately, I am not smart enough to be a general surgery resident.... I am an ortho resident in my chief yr (sports med and shoulder surgery next yr), technically however, I'm a PGY-7- I was smarter at one point in my life, and did 3 yrs of general surgery before seeing the light ;-)
So after facing my GI troubles on race day, I did a lot of htinking and going back to physiology.
I'm a heave guy - weigh in a 186 morn ing of race day. so there's a lot of fat insulation. can't dissipate body heat very easily. my body response to that is sweating more to make up for it to cool myself. that's why whene everybody would dump half a bottle of water on themselves on the bike, I would dump a full to kinda simulate me sweating. On the run, EVERY aid station involves me dumping ice in my hat - the reason is that the hands and the scalp are the 2 body sites in the body where heat can be lost. paraspinal musculature comes 3rd, and that's why de soto have actually made use of that in their most recent lines. I know for a fact they have tshirts with a pocket in the midline in the back. In an effortto keep my body cool on race day, not only did i dump ice in my hat, and cool my liquids off with ice first, I actually swallowed some ice, kinda like ice water lavage. unfrotunately ,I think that worked to my disadvantage, and that was part of the reason my GI shut down. I was not emptying from my stomach as easily as i would've loved. I would love to go back, and measure EXACTLY how much fluid total it was, bc the ice chips add to that fluid, but they were definitely implicated in my GI shutdown.
what shouldI have (and this is geared more towards the heavier people like me) done.
first things to keep: definitely kept the ice on my scalp, and kept it wet. ice down my belly does not affect that much with all the fat insulatoin in that area, so it's more bothersome running with chips. ice on the back is ok, and worth it, b/c has more effect than the front of the torso.
Things to do differently: no ice ingestion. I would rub ice on my arms, shoulder, and most areas in contact with direct sunlight. that will have a cooling effect. I am still not sure about the effects of cold fluids vs regular fluids. on one hand, cold fluids do decrease your core, but at the cost of slower gastric emptying. warmer (ambient temp) will move down quicker, be ingested easier, and be available to sweat off and cool your core. so it's a very tricky line, and I do not honestly know if there's ONE correct answer out there.....
thoughts? comments? would love to hear what you have to say about this
Kitima, unfortunately, I am not smart enough to be a general surgery resident.... I am an ortho resident in my chief yr (sports med and shoulder surgery next yr), technically however, I'm a PGY-7- I was smarter at one point in my life, and did 3 yrs of general surgery before seeing the light ;-)
So after facing my GI troubles on race day, I did a lot of htinking and going back to physiology.
I'm a heave guy - weigh in a 186 morn ing of race day. so there's a lot of fat insulation. can't dissipate body heat very easily. my body response to that is sweating more to make up for it to cool myself. that's why whene everybody would dump half a bottle of water on themselves on the bike, I would dump a full to kinda simulate me sweating. On the run, EVERY aid station involves me dumping ice in my hat - the reason is that the hands and the scalp are the 2 body sites in the body where heat can be lost. paraspinal musculature comes 3rd, and that's why de soto have actually made use of that in their most recent lines. I know for a fact they have tshirts with a pocket in the midline in the back. In an effortto keep my body cool on race day, not only did i dump ice in my hat, and cool my liquids off with ice first, I actually swallowed some ice, kinda like ice water lavage. unfrotunately ,I think that worked to my disadvantage, and that was part of the reason my GI shut down. I was not emptying from my stomach as easily as i would've loved. I would love to go back, and measure EXACTLY how much fluid total it was, bc the ice chips add to that fluid, but they were definitely implicated in my GI shutdown.
what shouldI have (and this is geared more towards the heavier people like me) done.
first things to keep: definitely kept the ice on my scalp, and kept it wet. ice down my belly does not affect that much with all the fat insulatoin in that area, so it's more bothersome running with chips. ice on the back is ok, and worth it, b/c has more effect than the front of the torso.
Things to do differently: no ice ingestion. I would rub ice on my arms, shoulder, and most areas in contact with direct sunlight. that will have a cooling effect. I am still not sure about the effects of cold fluids vs regular fluids. on one hand, cold fluids do decrease your core, but at the cost of slower gastric emptying. warmer (ambient temp) will move down quicker, be ingested easier, and be available to sweat off and cool your core. so it's a very tricky line, and I do not honestly know if there's ONE correct answer out there.....
thoughts? comments? would love to hear what you have to say about this
I just went back and read your RR. I think you were way behind in fluids by the time you were into your run. You are right about having a higher sweat rate than someone who is rail thin, but your diarrhea also added to your fluid losses. Also, I think it was hotter and drier than forecasted out there. The question is what was your urine output throughout the day?
I think during the first 3-4 hours of an IM the urine output should be a "large volume" (which is to me is enough pee that runs down your leg and gets your socks wet) every 2 hours. After hour 4, there should be some urine output every 2.5-3 hours. What is this based on? No real randomized double-blind study for sure! But after 4 hours on an IM, we are like post-op patients in the sense that we've been through some trauma and are mobilizing fluids. So the urine output should be 0.5ml/kg/hour---which for a 70 kg doode is 35ml/hour or 105ml over 3 hours. It only takes about 70 ml of urine in the bladder to make for urinary urgency. Factor in the progressive dehydration of 4 hours of exercise and I rounded it a moderate amount of urine output every 3 hours.
I think when dehydration has set in and GI motility is decreased to cause symptoms like nausea, bloating, regurgitation (but not vomiting) then the main objective should be to return blood flow to the GI system ASAP. There's no point in having a nutrition/hydration plan if you can't absorb it! In order to shunt blood to the gut, I think you've got to really slow down or stop (thereby decreasing the need for blood flow to muscles), cool yourself (thereby decreasing the need for blood flow to the skin to cool your body), and ingest small, frequent amounts of dilute liquid. As for the temperature of the liquid, if you are really deep into GI shutdown then probably cold fluids is a bad idea.
I think the key to keeping oneself from that point of dehydration is monitoring of urine output and GI motility (as in "Am I passing flatus? Am I burping more? Did I just reflux that gel?"). During the earlier hours of the race, you have all the fluids that you drank pre-race as a safety net. After 4 hours and even sooner if it's hot, it's a real balance to maintain enough blood flow to the gut and slow the rate of dehydration enough to be able to perform the exercise we want.
Touchee. seriously. In retrospect, and when i stopped around mile 19, and thought critically of why things were heading south for me over the past hour, I recognized I was behind on my fluids. That's exactly why i stopped to decrease heat production, cooled off my body by rubbing ice ALL OVER., and stopped any GI intake, it was not helping anyway..... It's interesting to see how we do RR with everything into account, but the only thing we can not simulate is the stress that you body is undergoing, and how your body reacts to that. eg was how Jim Hansen had hyponatremia (spot on with that diagnosis, btw ;-))
Also, reading from other RRs, it sounds like a lot of people had somm sort of physiologic imbalance, but the person with no medical background would have no clue on how to deal with those things. Matter of fact, even the person with a medical background (ME) was so dumbed out that such a thing is trivial. I even think about elec balance every time I'm drinking; but didn't keep that in my mind when i had diarrhea before driving my body into a brick wall FOR THIRTEEN LONG HOURS.....
WOW, this has been an enriching experience, at least in my case. I hope to learn from my (and everybody else's) mistakes; but would you have any thoughts on whether we should write a contigency plan for how we should react to things like this when they do go bad. The biggest example was you- you kept your cool, and didn't get flustered, analyzed your situation, and dealt with your problem on your bike. I, on the other hand, just executed, and drove the plan and my body, into a brick wall. ENer's (ALL OF THEM) can benefit from your background as a thinking doctor - wish i can claim the same... If you want to, I'd be happy to formulate a draft, and then you go over it?
Touchee. seriously. In retrospect, and when i stopped around mile 19, and thought critically of why things were heading south for me over the past hour, I recognized I was behind on my fluids. That's exactly why i stopped to decrease heat production, cooled off my body by rubbing ice ALL OVER., and stopped any GI intake, it was not helping anyway..... It's interesting to see how we do RR with everything into account, but the only thing we can not simulate is the stress that you body is undergoing, and how your body reacts to that. eg was how Jim Hansen had hyponatremia (spot on with that diagnosis, btw ;-))
Also, reading from other RRs, it sounds like a lot of people had somm sort of physiologic imbalance, but the person with no medical background would have no clue on how to deal with those things. Matter of fact, even the person with a medical background (ME) was so dumbed out that such a thing is trivial. I even think about elec balance every time I'm drinking; but didn't keep that in my mind when i had diarrhea before driving my body into a brick wall FOR THIRTEEN LONG HOURS.....
WOW, this has been an enriching experience, at least in my case. I hope to learn from my (and everybody else's) mistakes; but would you have any thoughts on whether we should write a contigency plan for how we should react to things like this when they do go bad. The biggest example was you- you kept your cool, and didn't get flustered, analyzed your situation, and dealt with your problem on your bike. I, on the other hand, just executed, and drove the plan and my body, into a brick wall. ENer's (ALL OF THEM) can benefit from your background as a thinking doctor - wish i can claim the same... If you want to, I'd be happy to formulate a draft, and then you go over it?
thoughts?
I'll send you what I've written so far (via PM) and see what you think...Glad to know someone else is thinking about this too!
You guys are onto something here- I call it "EBT". Evidence based training. Seriously, from a med-phys perspective, I think there is much to be learned here.
You guys are onto something here- I call it "EBT". Evidence based training. Seriously, from a med-phys perspective, I think there is much to be learned here.
We're cooking up a document about race day monitoring of hydration and GI function and electrolyte mishaps. Will put it up on the forum and/or wiki soon!
but just out of curiosity, and i want your opinion on how i analyzed it race day when i was going down. It was one of 4 problems:
1. too much water: Too much water, but enough sodium = increased urine output. The problem is too much water and too little sodium = HYPONATREMIA (low sodium levels in blood). The early symptoms are nausea/vomiting, headache, lethargy, fatigue which then progresses to muscle spasms/cramps/weakness, irritability, seizures and lastly decreased consciousness then coma. In the IM medical tent, people with hyponatremia will present will the above symptoms and sometimes profound mental status changes. One year at IMLP, a guy was pulled off the bike course with hyponatremia. He laid in the medical tent cot on his back with his feet in the air pedalling because he thought he was still on the course. Most hyponatremic athletes in the IM med tent will have weight gain and some swelling. The treatment is to have them take in salty foods until they start peeing.
2. too little water: Dehydration! The first symptoms are dry mouth/sticky saliva, reduced urination with dark/concentrated urine, and fatigue. The next stage will present with even more dryness in the mouth and further decrease in urination with really dark urine, increased heart rate, decreased appetite, slight dizziness, cold hands and feet. Severe dehydration presents with changes in mental status, more dizziness/lightheadedness, inability to get up and walk, further increased heart rate, increased respiratory rate, then loss of consciousness.
3. too much salt: With normal kidney function, you will simply feel more thirsty if you take too much sodium. In extreme cases of excessive sweating and decreased intake of fluids, the symptoms are lethargy, weakness, and irritability.
4. too little salt: See above #1
or a combination, and that's where it become tricky......
alright, I better shut up, and wait for what you have say
From what I've seen in the IM medical tent, the major problems are dehydration and (not as common as dehydration) hyponatremia.
so, basically we're both down on the same line of thought. I was actually trying to keep things simple on the forum, in case somebody wanted to read things up, without them thinking - WOOOOOW, this is way toooo much for my simple mind
I'll need to look up the composition of sweat, and how that's affected by the person's osmolarity. b/c obviously later on in the race, that might be different. unfrotunnately, to make things even more complicated, if you're in one state, your sweat might be different than if you're in another....
furthermore, the problem arises in making it simple on the course with replacement.
In the meantime, I better pull out my second edition of "The ICU Book" where's that blue book now. I'm sure it's been collecting dust somewhere......
Comments
Kitima, unfortunately, I am not smart enough to be a general surgery resident.... I am an ortho resident in my chief yr (sports med and shoulder surgery next yr), technically however, I'm a PGY-7- I was smarter at one point in my life, and did 3 yrs of general surgery before seeing the light ;-)
So after facing my GI troubles on race day, I did a lot of htinking and going back to physiology.
I'm a heave guy - weigh in a 186 morn ing of race day. so there's a lot of fat insulation. can't dissipate body heat very easily. my body response to that is sweating more to make up for it to cool myself. that's why whene everybody would dump half a bottle of water on themselves on the bike, I would dump a full to kinda simulate me sweating. On the run, EVERY aid station involves me dumping ice in my hat - the reason is that the hands and the scalp are the 2 body sites in the body where heat can be lost. paraspinal musculature comes 3rd, and that's why de soto have actually made use of that in their most recent lines. I know for a fact they have tshirts with a pocket in the midline in the back. In an effortto keep my body cool on race day, not only did i dump ice in my hat, and cool my liquids off with ice first, I actually swallowed some ice, kinda like ice water lavage. unfrotunately ,I think that worked to my disadvantage, and that was part of the reason my GI shut down. I was not emptying from my stomach as easily as i would've loved. I would love to go back, and measure EXACTLY how much fluid total it was, bc the ice chips add to that fluid, but they were definitely implicated in my GI shutdown.
what shouldI have (and this is geared more towards the heavier people like me) done.
first things to keep: definitely kept the ice on my scalp, and kept it wet. ice down my belly does not affect that much with all the fat insulatoin in that area, so it's more bothersome running with chips. ice on the back is ok, and worth it, b/c has more effect than the front of the torso.
Things to do differently: no ice ingestion. I would rub ice on my arms, shoulder, and most areas in contact with direct sunlight. that will have a cooling effect. I am still not sure about the effects of cold fluids vs regular fluids. on one hand, cold fluids do decrease your core, but at the cost of slower gastric emptying. warmer (ambient temp) will move down quicker, be ingested easier, and be available to sweat off and cool your core. so it's a very tricky line, and I do not honestly know if there's ONE correct answer out there.....
thoughts? comments? would love to hear what you have to say about this
I just went back and read your RR. I think you were way behind in fluids by the time you were into your run. You are right about having a higher sweat rate than someone who is rail thin, but your diarrhea also added to your fluid losses. Also, I think it was hotter and drier than forecasted out there. The question is what was your urine output throughout the day?
I think during the first 3-4 hours of an IM the urine output should be a "large volume" (which is to me is enough pee that runs down your leg and gets your socks wet) every 2 hours. After hour 4, there should be some urine output every 2.5-3 hours. What is this based on? No real randomized double-blind study for sure! But after 4 hours on an IM, we are like post-op patients in the sense that we've been through some trauma and are mobilizing fluids. So the urine output should be 0.5ml/kg/hour---which for a 70 kg doode is 35ml/hour or 105ml over 3 hours. It only takes about 70 ml of urine in the bladder to make for urinary urgency. Factor in the progressive dehydration of 4 hours of exercise and I rounded it a moderate amount of urine output every 3 hours.
I think when dehydration has set in and GI motility is decreased to cause symptoms like nausea, bloating, regurgitation (but not vomiting) then the main objective should be to return blood flow to the GI system ASAP. There's no point in having a nutrition/hydration plan if you can't absorb it! In order to shunt blood to the gut, I think you've got to really slow down or stop (thereby decreasing the need for blood flow to muscles), cool yourself (thereby decreasing the need for blood flow to the skin to cool your body), and ingest small, frequent amounts of dilute liquid. As for the temperature of the liquid, if you are really deep into GI shutdown then probably cold fluids is a bad idea.
I think the key to keeping oneself from that point of dehydration is monitoring of urine output and GI motility (as in "Am I passing flatus? Am I burping more? Did I just reflux that gel?"). During the earlier hours of the race, you have all the fluids that you drank pre-race as a safety net. After 4 hours and even sooner if it's hot, it's a real balance to maintain enough blood flow to the gut and slow the rate of dehydration enough to be able to perform the exercise we want.
Touchee. seriously. In retrospect, and when i stopped around mile 19, and thought critically of why things were heading south for me over the past hour, I recognized I was behind on my fluids. That's exactly why i stopped to decrease heat production, cooled off my body by rubbing ice ALL OVER., and stopped any GI intake, it was not helping anyway..... It's interesting to see how we do RR with everything into account, but the only thing we can not simulate is the stress that you body is undergoing, and how your body reacts to that. eg was how Jim Hansen had hyponatremia (spot on with that diagnosis, btw ;-))
Also, reading from other RRs, it sounds like a lot of people had somm sort of physiologic imbalance, but the person with no medical background would have no clue on how to deal with those things. Matter of fact, even the person with a medical background (ME) was so dumbed out that such a thing is trivial. I even think about elec balance every time I'm drinking; but didn't keep that in my mind when i had diarrhea before driving my body into a brick wall FOR THIRTEEN LONG HOURS.....
WOW, this has been an enriching experience, at least in my case. I hope to learn from my (and everybody else's) mistakes; but would you have any thoughts on whether we should write a contigency plan for how we should react to things like this when they do go bad. The biggest example was you- you kept your cool, and didn't get flustered, analyzed your situation, and dealt with your problem on your bike. I, on the other hand, just executed, and drove the plan and my body, into a brick wall. ENer's (ALL OF THEM) can benefit from your background as a thinking doctor - wish i can claim the same... If you want to, I'd be happy to formulate a draft, and then you go over it?
thoughts?
I'll send you what I've written so far (via PM) and see what you think...Glad to know someone else is thinking about this too!
cancelling dinner plans, and waiting at my computer
. jk.
shoot it my way: hasanbaydoun@gmail.com
but just out of curiosity, and i want your opinion on how i analyzed it race day when i was going down. It was one of 4 problems:
1. too much water
2. too little water
3. too much salt
4. too little salt
or a combination, and that's where it become tricky......
alright, I better shut up, and wait for what you have say
Kitima, don't know how to send PMs yet, can you send me your email. LOV it, or shoot me n email? thanks
Ok Kit and Hasan,
Have been following your discussion and I am fascinated!! Please please publish something for the team, it would be invaluble!
You guys are onto something here- I call it "EBT". Evidence based training. Seriously, from a med-phys perspective, I think there is much to be learned here.
We're cooking up a document about race day monitoring of hydration and GI function and electrolyte mishaps. Will put it up on the forum and/or wiki soon!
From what I've seen in the IM medical tent, the major problems are dehydration and (not as common as dehydration) hyponatremia.
so, basically we're both down on the same line of thought. I was actually trying to keep things simple on the forum, in case somebody wanted to read things up, without them thinking - WOOOOOW, this is way toooo much for my simple mind
I'll need to look up the composition of sweat, and how that's affected by the person's osmolarity. b/c obviously later on in the race, that might be different. unfrotunnately, to make things even more complicated, if you're in one state, your sweat might be different than if you're in another....
furthermore, the problem arises in making it simple on the course with replacement.
In the meantime, I better pull out my second edition of "The ICU Book" where's that blue book now
. I'm sure it's been collecting dust somewhere......
-hb