The Hyponatremia Cocktail Du Jour And The Big Fat ‘F’ (part 2 of 3)
Game for a healthy cocktail that’ll give you a lift when you need it most?
No Jiggers Needed For Hyponatremia
No jiggers needed. No muddling or shaking. Not even pricey ingredients. A little bit of creativity, a little bit of experience and a little bit of sodium and water is what it takes.
Consuming this cocktail du jour becomes vital if you are an ultraendurance athlete or like me, a newbie to the ultraendurance trail-running scene. Paying close attention to the mix and what appears to be the innocuous powdery white substance otherwise thought of as salt, could be a matter of life and death. Quite literally.
Sidenote: salt is actually made up of sodium and chloride.
As endurance participants, whether runners, triathletes, hikers or even tree planters, being aware and heeding the signs your body gives you in the heat of living passionately is central to your success. Part and parcel to this success, is understanding the critical role that sodium and water play.
The trick is, you want this cocktail to give you a lift in the right direction. That is, a lift to the finish line of your race and not to the top of your elusive staircase towards the white light. The trick is, it’s all in the mix. Focus on balance. The right little bit of sodium to the right little bit of water.
Adjusting the mix at the wrong times could lead you to a long and hard journey of recovery. Not adjusting the mix at all, could lead you to the road of no return. This game you could find yourself in is known simply as Hyponatremia.
This post is the second of a three-part series on my first ultra and my first trail-running race. Not just any trail-running race — but the infamous Canadian Knee Knacker. It has been a year of fearing for this race, training for this race and finally running it only to end up past the finish line and in the hospital. Important lessons have been learned — including the priceless Perhaps the only limits to the human mind are those we believe in. ~ Willis Harman.
- Part One: Ever Do The Knee Knacker?
- Part Three: Ensure you don’t miss the surprises that lie in the next post — subscribe to this blog and receive the third part by email.
Unless you’re not pushing yourself, you’re not living to the fullest. You can’t be afraid to fail, but unless you fail, you haven’t pushed hard enough.
~ Dean Karnazes
Spinning Out Of Control
What does failure mean exactly?
1 Hour After The Race Ends
Hyperventilating, I can’t seem to catch my breath. Didn’t feel this way through the whole 9 hours and 40 minutes it took to run and finish the knarly, 30-mile Knee Knacker. My body spins, what seems, out of control and I begin to wish for a hospital.
I blink. A hospital? Anyone who knows me, knows I work hard to keep a far distance from sterile white lab coats and sterile white rooms. Something is definitely not right here.
I find myself lying up and limp against the backseat of my car. I can’t seem to find the strength to move my body, let alone keep my eyelids up.
My lip is shivering, my arm is shivering, my leg is shivering. The fact that it’s my left side shivering is not clicking. The only thing clicking is the bare fact: I’m shivering and it’s an incredibly beautiful hot day in Vancouver, British Columbia (a day we’ve been craving for all year long).
3/4 Hour After The Race Ends
Drop off a fellow Knee Knacker participant, drop off my parents, then head home to lie on the sofa and sleep. That is the sole aim of my game.
I need to get out, please, stop the car.
Overcome by dizziness, a simple breath of fresh air is all I want. Ohhh! Tenderness and even pain seems to be setting in what I think is far too quickly in those calves. I can no longer lift my legs out of the car.
I can’t get out, please help lift me out of the car.
Maybe I need a sip, maybe some Ginger Ale. Pee – I gotta go. Forget it, I went. Another tug at the alarm goes off — since the last half of the race, I have felt that every sip of water has almost immediately been followed by a pee.
Sidenote: a sip at this point in time will worsen the Hyponatremic state. What is needed is a major dose of sodium. What could have been happening with the pee? The body was taking care of itself. The body had very little sodium in it and without the right amount of sodium, liquid is unable to be absorbed by the system. With excess of water in the body, a pee reaction triggers.
What is happening is something out of the ordinary. Something new. But then again, this is my first trail race and my first ultra. Is this a common experience? I think back to the two books written by whom has become one of my mentors — Mr. Dean Karnazes. He’s tough. Simply tough it out Doris.
1 Hour After The Race Ends (continued…)
My mom, my dad and husband – my amazing and supportive family that followed me through the day’s unfolding event. From the race start on the west side of Vancouver, across several mountains to the race end, 30 miles away and on the east side of Vancouver.
They are talking and it’s all sounding kind of filtered. Kind of like listening with an ear filled with water after diving into a pool. The thing is I haven’t been diving. I have only been running a race which I’ve been waiting and fearing for all year long and wondering if I could make it through it’s finish line.
My mom suggests my dad hail down an ambulance. My dad runs across the street to where a first-time community event is taking place, with a fortunate stroke of serendipity, today and right now. These decisions save my life.
A little scene is developing on the roadside of my familiar childhood neighbourhood and I appear to be at the front and center.
This is all feeling pretty surreal. I am a few steps from where I used to have my lemonade stand as a child, from where my sister sat her hamster on top of my skateboard, where we laughed watching the hamster roll with fear on a flat board with wheels down to the bottom of our block.
1 Hour, 15 Minutes After The Race Ends
I hear an unfamiliar voice. No — two unfamiliar voices, then three, then five. I feel pricks in my hand, and cold electrodes on my chest. I am very thankful – the ambulance.
Control your breathing. Tell your wife she has to control her breathing. This is repeated over and over, but they don’t seem to understand, I can’t control my breathing.
I attempt to hold my breath and like a puffer fish my cheeks blow up with air. How the heck do they suppose I control my breathing?
I feel myself be lifted up and in. I feel my clothes stripped off and I hear a distant voice — it’s my mom: and remember, change your underwear every morning. You never know what your day will bring. The rest of me is caked in mud and salt and scratches from the infamous Vancouver race I have just partaken in and completed.
We are off. A moment of silent relief. Gosh, my first ambulance ride, my first hospital visit. At different times in my life, I have wondered if I would ever get this dreaded encounter. My stomach clenches and I lunge uncontrollably towards an open bag.
Hey, it’s kinda cool — my ambulance encounter is tied to the Knee Knacker! Well, kinda cool…
2 1/2 Hours After The Race Ends
The curtain flies open in the Emergency ward.
The doctor speaks quickly and coldly. She informs me my CK level (Creatine Kinase) is at 8,000 — 100 is where it should be. You are at a danger point and this could lead to Kidney Failure.
My eyes shoot open. Kidney Failure!?
A wave of near déjà vu washes over me. It was only last week I discovered there exists a relationship between endurance athletes and renal failure. The June issue of TrailRunner magazine describes Diana Finkel’s experience and her brutal Hardrock 100-Mile Endurance run. How she placed second and how her performance came at a cost. Two days after the race, she lay in a hospital bed with kidney failure.
Like a swollen marshmallow, I lay socked in the gut with shocked disbelief. This is my first ultra and first trail-running race. I have a marathon a month to run and I’m already signed up. Kidney failure?
A bracelet is slapped on me, an intravenous catheter inserted and my race to flush out the toxic residue begins.
We are keeping you in through the night and through tomorrow. You will be poked every two hours for a blood sample. Your CK level needs to be brought down.
5 Hours After The Race Ends
I doze in and out of sleep.
Every two hours I am prodded and warned you need to pee.
10 Hours After The Race Ends
I am prodded and warned if you don’t go pee, you will get the bag hooked up to you.
12 Hours After The Race Ends
My face lunges for another kind of bag as my stomach convulses once again.
I begin to feel like Violet Beauregard in Charlie and the Chocolate Factory when she begins swelling and finally succumbs and explodes like a balloon too far gone.
Bags after bag of saline solution is pumped in. Vials and more vials of blood pumped out.
13 Hours After The Race Ends
A huge sigh of relief. I have to go pee! The thought of dealing with the intervenous catheter was one thing, the thought of dealing with a pee bag was scaring the bejesus out of me.
The 6:30 morning gun shoots off and we are off — all 198 participants.
This race is different, in that a trail-running group is setup a couple months prior to the race, to help familiarize yourself with the intense terrain and amazing trail system on Vancouver’s North Shore. Partaking in this training has been critical to my success in crossing the finish line. My discoveries have been simple as I peel away at only the first layer of an incredibly sweet onion that tempers my impatience to delve deeper far too quickly into this new world of ultras and trail-running.
One thing I do learn — my completion time will most likely be about 9 and 1/2 hours. Another discovery — a fuel and hydration plan is critical.
My plan Stan? a granola bar for breakfast, 2 gel packs every hour (Gu being the gel of choice), an electrolyte pill (37 mg of sodium) along with a litre and 1/4 of water at every major station. Real food on my training runs have been limited, so I don’t include it in my plan today. If I feel up to a bite, I’ll take it — we’ll see how it goes.
Everything ticks according to the clock. My gels, my water and just over 1/2 way through this foray (20 miles in) I decide to fend off some twitches of tenderness in my left knee and left elbow with a Tylenol. Pill-popping is not my thing — and this decision comes only after a bit of inner debate — I want to finish this thing, and I have no idea if this pain intends to toy with the ticker. What harm could it do? Right?
The result is a finish! The feeling overwhelms with a deafening smile. This moment has been played over and over and over again who knows how many times. Protocol takes over and I do the refreshing dip in Deep Cove’s waters.
Summary: 7 litres of water, a few swigs of flat cola, one watermelon slice, the thought of food was nauseating, 2 pretzels on my lips forced an unfeminine spit, one Tylenol, and 3 electrolyte tablets.
Do you see the errors of my ways? I certainly didn’t — but follow along and see what happens.
17 Hours After The Race Ends
A new morning and a new copy of the TrailRunner issue — August. I can’t believe my eyes.
One of the main articles is entitled Keeping The Glass Half Full and is about improving performance with proper hydration and electrolye replenishment.
The third page of this article beautifully diagrams a helpful three row by three column grid entitled The Delicate Water-Electrolyte Balance. The first column, third row describes my situation — Hyponatremia with overhydration DANGEROUS! Hello!
The impeccable timing of this magazine issue doesn’t end there.
The Letters to the Editor includes one critical letter that follows up the story from the TrailRunner magazine’s last issue, about Diana Finkel and her kidney failure experience.
The follow up letter, entitled IMPORTANT DETAIL, informs readers how …the author of that Diana Finkel article in the previous issue, neglected to include a very important detail — the fact that, as Diana relayed to me, she took a single dose of 800mg of ibuprofen in the last four hours of the race at a time when her legs were cramping and she was repeatedly falling. …This article leaves the reader with the fear that in their next ultra, the same horrible complication could happen to them. Renal failure in ultra runners is not random — it is predictable.
Myoglobin, the breakdown product from muscle injury (rhabodmyolysis), is cleared by the kidneys. This works well unless you get dehydrated and the body decreases blood supply to kidneys by 75 to 80 percent. Ibuprofen is an effective pain killer, but like most NSAIDS, it is also exclusively metabolized by the kidneys — in my opinion this is what pushed Diana Finkel from rhabdomyolysis into renal failure.
It only takes one dose at the wrong time.
~ John Hill, Aurora, Colorado DO, FACSM, Professor, University of Colorado, Co-Medical Director Leadville Trail 100
Great information! Just what I needed yesterday — before the race!
19 Hours After The Race Ends
Good morning Doris, I’m your neuphrologist and these are my interns (five of them). So you are into ultras and you ran for 9 hours and 40 minutes eh? Congratulations, what you did is amazing! But you can’t run any more races like this.
I offer a sentiment of kindness with a gentle smile, as I want to get my butt out of this place. My annoyance overtakes and I offer there are many variables that play into this mix. The amount I have trained, my fuel plan, my hydration plan — no one has asked me any of those questions and you suggest I stop running? I took a Tylenol, now read this Letter to the Editor.
26 Hours After The Race Ends
I beg to be released into the world again. I’ll do anything and everything they tell me (the not run part is being debated in the deep recesses of my mind).
Drink one litre of chicken soup with an extraordinary amount of salt added in.
Whatever you say and thank you!
The Big Picture
What exactly is Hyponatremia? It is a condition where you have ‘low concentration of sodium in the blood’ and is sometimes called water intoxication due to the neurological symptoms.
Sodium plays an extremely important role in water balance and muscle contraction. Sodium is required to draw water through permeable membranes in the body and thereby distribute fluid throughout the body. If your sodium levels in the blood get too low, moving water across permeable membranes becomes difficult and you will become dehydrated – even if you have enough water in your body, your body can’t get to it.
A patient can find themself spiraling down a slippery slope if they’re not aware and neglect to alter their course. Symptoms include: decreasing performance, fatigue, nausea, hyperventilation, mild hyponatremia, cerebral edema, seizures, coma, kidney failure.
The truth is, we are not created equal and some of us are more susceptible to Hyponatremia than others. According to Suzanne Girard Eberle, author of Endurance Sports Nutrition, at greater risk are female endurance participants, those at the back of the pack, athletes who have troubles with cramping, and those who have had difficulties getting acclimitized to heat.
Experience shows the Hawaiian Triathlon sees a large percentage of men DNF because of Hyponatremia. Similarily, since 1989, the Grand Canyon has been experiencing an ever-increasing rate of hyponatremia.
What becomes vitally important to our success is staying ahead of the sodium curve!
The Big Fat F
A big F for you cries out my much sought after sports doctor from a miniscule beige room at our esteemed University of British Columbia sports medicine facility.
To get to see a UBC Sports specialist takes months in British Columbia. The fact that I am running a marathon a month for my fundraising initiative and the Make-A-Wish Foundation, helps get me in after two weeks of my hospitalization.
Overwhelmed with excitement to get it straight from our famed practitioner, I rush across the city, driving far too fast to get to the appointment that is sure to send me onto the next level of personal discovery and enlightenment.
I await in his office, he enters, and delivers his expert advice: You failed, you get an ‘F’.
Staring incredulously into his eyes, eagerness and excitement yield to unease and to appall. A few thoughts float through my mind and finally one thought accompanies my voice. I don’t think you were properly informed Doctor, I finished the race in 9 hours and 40 minutes. I made it under the 10 hour cutoff. I felt fine and jumped in the water to refresh.
The doctor: He stares into my eyes and repeats, you failed. You ended up in emergency. You are here for my advice. Don’t run for two months, then work your way up to a marathon again, but slowly.
Me: The race was on July 9th, my next marathon is August 25th. I have been training and feel fine. I am here to understand what happened exactly, to get a hydration plan, a fuel plan and a plan to run faster.
The doctor: You’ve come to the wrong place. My job is to give you advice on what happened to you. Find a nutritionist and coach for anything else. Don’t run the next marathon. Monitor your sodium intake and adjust accordingly.
Doctor’s pearls of advice:
* increase your sodium intake a week prior to your race
* if you feel dizzy, take a sodium tablet.
Me: what if I take too much sodium?
The doctor: you pee it out, don’t worry about it.
I leave feeling a huge sense of disappointment. I leave with a mission to research and learn on my own. I leave with a mission to run at least 1/2 of the next marathon and decide at that point — whether to run the next half.
Learn what happens and my discoveries in part three of this three-part series. Subscribe to this blog and receive the third part by email.
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