Running Like A Question Mark
Posted by Jeremy Windsor on Apr 1, 2022
In long distance multi day events Exercise Induced Hyponatraemia (EIH) can be a real problem. In May 2021, Damian Hall broke the record for running the Wainwright’s Coast to Coast. The 185 mile route, from St Bees to Robin Hood’s Bay, was completed in a phenomenal time of 39 hours and 18 minutes. But all didn't go to plan. In a recent article in Fell Runner, Damian gave an extraordinary account of his experience of EIH. He has very kindly allowed us to republish it here. If that wasn’t enough, we are also able to share a fascinating account by Dr Nicki Lygo, who provided medical support for Damian on his run. Finally, Damian and Nicki answered a few questions…
Let me tell you a story about a time I drank too much, behaved like a drunken fool (or rather, a drunken child, according to Andy Berry) but hadn't actually consumed any alcohol.
It's all Matt Neale's fault. Not the drunken bit. But rather the idea to go record bothering on Wainwright's Coast to Coast. After my Pennine Way run last year, I was looking for something similar and he pointed out the 185 mile trans-England trail had a long standing Mike Hartley record. Mike Hartley records have become quite the thing. Lockdown has not been kind to his record collection.
In 1990 Hartley ran it in 39 hours, 36 minutes and 52 seconds beating his friend Mike Cudahy's record by seven hours. Mike maintained 5mph throughout the Lake District and barely slowed from there. It's approximately 0.6mph faster than his record breaking Pennine Way run the previous year. "Mike set the bar so high that I don't think anyone has had a serious attempt at it since then," said FRA long distance records custodian Martin Stone. Gulp. I didn't mind the distance. But I was wary of that speed.
Conceived by the flambuoyantly whiskered guidebook author Alfred Wainwright, Coast to Coast is a popular hiking route. The approximate 185 mile traverse with upwards of 20,000 feet ascent starts at St Bees, Cumbria, bounces through the Lake District, the Yorkshire Dales, the flat Vale of York, the North York Moors and down the coast to Robin Hood's Bay.
Like the Pennine Way, I'd hiked the Wainwright's Coast to Coast way before I had any idea people could run such things. The excellent Northern Traverse (NT) race follows the same route but with minor tweaks and the C2C route has changed slightly down the years, but NT race director and Open Tracking owner James Thurlow was a huge help in tracing the record route accurately.
I wanted to use the run to draw attention to our climate and ecological emergency, by picking up litter, fuelling without animal products, largely without creating plastic waste, by using local pacers wherever possible, by offsetting unavoidable emissions from travel. It would have been much better, of course, if I could have done the run without al this help and car journeys. But you don't break Mike Hartley records that way. It's an uncomfortable paradox.
Although Damian didn't complete his first marathon until 2012, in the decade since he's set the ultrarunning world alight. Not only has he positioned highly in some of the world's most testing ultramarathons, he's set a host of fastest known times (FKT's), including those for the Pennine Way, Paddy Buckley Round and the South West Coast Path
A road crew of Nicki Lygo, Tim Laney, Mark Townsend and a team of support runners came together quickly, many of whom had somehow not been put off by helping me on the Pennine Way. The forecast was mixed, not bad enough to call it off. Those early miles with Sam Tyrer and Rory Harris were smooth and easy. I needed to build a buffer on Mike's record, in case of any mishaps later. But I also needed to get through the Lakes without doing myself some mischief.
Old pals Kim Collison and Paul Tierney joined me at Honister and we yabbered away in hail, brief showers, but mostly sunshine as we skipped across the fells. Chris Tyrer and Steve Birkinshaw swapped in at Patterdale, starting with the long slop up to Kidsty Pike, the highest point on the route. A few soggy fields and we were in Shap, 60 miles and 11 hours in, and the end of the start. I was somehow two hours ahead of Hartley's time. But I felt wearier than hoped and my hips were stiff. Had I overcooked it?
Mike Hartley and Martin Stone turned out to see me in Shap, which gave me a huge lift. With my new support runners Mark Kerry, Paul Nelson and Jack Eyre, an easier pace allowed three slices of vegan pizza, generously donated by my amazing pacers, to slide down my gullet.
Shap to Kirkby Stephen was the wettest section so far. My saintly crew provided fresh chips, soup and tea, and I changed into a dry pair of inov-8's, which were sensational again, as they had been on the Pennine Way. In the gloaming, Matt Neale, Andrew Higgins and Mark Clarkson dragged me up to the Nine Standards. The terrain was minging, slippery, sloppy moorland. My tummy felt full or possibly bloated.
Arrival at Keld at around midnight, signalled halfway. I knocked back some delicious rice pudding and asked for no more electrolytes in my drinks, which I thought might help my tummy settle. It was only a temporary measure. But I forgot to ask for them again.
Two strangers were out ringing cowbells at Reeth, long after midnight. I was slowing a little, but we were still around two hours up on schedule. We maintained the gap to the cobbled streets of Richmond at 3.30am. Jason Millward and Paul Booth joined me for a long flat spell through fields at first, then roads, often in drizzle. They were great company perking me up with Dad jokes.
EIH was first diagnosed in a 46 year old woman who dropped out of the 1981 Comrades Marathon in South Africa after approximately 70kms. She was diagnosed with dehydration and given 2 litres of intravenous fluid at the race medical centre. On the drive home she suffered a seizure and was admitted to hospital where she was found to have a plasma sodium concentration of 115 mol/L (normal range 135-145 mmol/L). She was eventually discharged 6 days later and went on to make a full recovery
It was raining in the village of Danby Wiske at 6.05am, 140 miles and 24 hours in, still two hours and change ahead of the record. Really everything was going top banana. Yet I was feeling just a little bit ... strange.
"In the North York Moors it was p***ing it down," remembers Tim. "It was cold, horrible. I was really worried about you." I don't remember anything about the Lord Stones rendezvous point. Jayson Cavill and Andy Berry took over support runner duties. We seemed to go up steep hills in the rain a lot. I remember clambering over some rocks. there was a crew stop at the Lion Inn apparently. I seemed cold, I'm told. But it was a fight to make me put on a mid-layer.
I started rudely questioning Andy and Jayson. "Are you sure we're going the right way?" Everything looked the same. Fog and bog. Bending into the rain and wind, Andy and Jayson heroically forming a protective shield against the weather for their ungrteful burden.
At Galisdale (3.30pm, 36 hours and 170 miles in, around 1 hour and 30 minutes ahead of record) I half remembered trying to remove my merino mid layer without taking off my stormshell. I fell over on the moor so pathetically people thought I'd done it on purpose. Andy told my support crew I was finished, but rather more colourfully.
Nicki Carr Walls, Sam Dunwell and (later) Joe Leadley, Danny Walls ad Neil Webster joined me. "Where are these people taking me?" I asked my crew. I was frequently losing my balance. A supportive hand in the small of my back saved me several times. the amazing Nicki Lygo, a doctor, was starting to twig what was going on, the potentially fatal state I was in, and asked my pacers not to let me drink anymore.
Over hydration is the commonest cause of EIH. This tends to result in a reduction in the concentration of both plasma and urinary sodium. However in some individuals the urine concentration is normal or even raised. This may be due to the release of anti diuretic hormone (ADH) from the pituitary gland. Working at different sites in the kidney, this hormone increases the reabsorption of water and results in the concentration of urine. A wide range of factors can trigger a release of ADH. These include - pain, nausea, anxiety and drugs such as ibuprofen and other NSAID’s (non steroidal anti-inflammatory drugs)
What was once a two and a half hour advantage over Hartley's record had reduced to 20 minutes. Mark said, "You really need to get on and do this" - almost sinister at the time, but absolutely needed. Tim and Matt Green from Summit Fever Media joined me, the latter endlessly nagging me to get a shift on. I hated the idea people might feel disappointed in me. But couldn't seem to do anything about it. I felt so weak.
I don't know when I started "running like a question mark", as Nicki put it. While we can't be sure without blood tests at the time, I was very probably acting like a drunken child because my brain was swelling and I was in a state of hyponatraemia (over-hydration / low sodium). Which may sound like a good thing for a bear of little brain like me. But it isn't.
It was a glorious evening as I staggered with a comical lean down the steep cobbles to Robin Hood’s Bay beach. Kind locals clapped and cheered. I mumbled something indecipherable as I held my children's flag and gave a goofy grin. Chocolate pudding was smeared on my face. I didn't know or ask what my time was. (It was 39 hours, 18 minutes and 40 seconds - just 18 minutes ahead of Hartley's time). I wasn't yet aware I had nearly cocked up in a much more serious way.
It feels both reassuring and alarming that despite having done 50-plus ultra-distance races and challenges, I've had no knowing experience of hyponatraemia before. I'm embarrassed I got into such a state. But also feel a duty to share the lesson learned.
We think I consumed 400ml liquid/hour maximum, including food, which doesn't sound like loads. But it was cool, well below 10 degrees C, so maybe I wasn't sweating out liquid as much as normal. Cutting out my electrolytes may have been significant. But probably not as significant as the fact I drank just a little bit more than perhaps I needed to, for 39 hours. I usually drink to thirst. but this time I thought I could hydrate just a little bit better and was aiming for 500ml/hour. Which probably wasn't right for me in those conditions.
I was kindly handed a pint at the end. In retrospect perhaps it's telling that I didn't really want to drink it. I'd been behaving like a drunken fool for several hours already.
Dig deep into your memory banks and you might recall the phenomenon of osmosis - the process that describes the movement of fluid from dilute to a more concentrated solute across a semi permeable membrane. In hyponatraemia, water moves from the circulation and into the brain. The resulting swelling leads to a wide range of neurological symptoms such as headache, fatigue, confusion, restlessness and irritability. Left untreated, seizures and coma may occur
Thanks Damian, now over to Dr Nicki Lygo…
The first clue that there was a potentially significant problem with Damian, was the development of fairly good-going confusion, well over halfway in. He arrived at Glaisdale, at around the 150-mile point and asked where these people (the pacers) were taking him. After seeing many a runner in this state owing to sleep deprivation, this wasn’t as dramatic a finding as you might think. He was otherwise running well and making relatively good progress. On the Winter Spine Race, a long chilly trot up the hilly Pennine Way in January, some athletes have been known to call friends or family from the trail and ask what they are doing on a hill or where they are supposed to be going. It was only once that he’d set off from the Glaisdale road support point that we processed the fact that Damian had run much longer distances and been awake for longer stints, without any cognitive deficit at all. Worryingly, this suddenly felt unlikely just to be sleep monsters calling.
Interestingly, we coincidentally gave the baffled Damian some very salty chips from a local pub at this stop, which seemed to go down well, but I must confess that hyponatraemia still hadn’t actively occurred to me, so I can’t take any credit for a light-bulb, record-saving (or life-saving) mental moment. Besides anything else, it was cold and wet - not exactly typical conditions known for this complication.
A fascinating short film of Damian’s record breaking Coast to Coast run can be found here
When we next saw Damian, as a brief run-by at High Bride Stones, we made a tracker change as the battery was running low. Whilst Damian was coherent and orientated enough to understand broadly what we were doing, he wasn’t quite co-coordinated enough to unzip the pack pocket to make the switch. But it was cold. We all have difficulty with fine motor skills in the cold, right? Brushing that potentially alarming, but also potentially benign issue aside, overall, it was fair to say that if anything, he was slightly better than at Glaisdale, something I now put down to the salty chips. Despite this, my concern levels were growing.
By Hawkser, the final road support point just 4 miles before the end of the Coast to Coast trail, Damian was running somewhat like a question mark. As they approached, I shouted over to one of his pacers and asked how long he had been leaning and requested a general welfare update. The reply was immediate - he had pain in his ankle and had mentioned a tendon problem. That was a reassuring response - this could be an antalgic gait. Perhaps Damian was simply leaning away from his pain? But he didn’t look quite right. And he certainly had lost the chatty demeanour that carried him through all but a couple of midnight hours on his 260 mile Pennine Way run the previous year. I didn’t give the crew any more fluids at this point. I told another pacer he could have small sips of his remaining half-full flask of tea for mouth comfort.
I chatted to Damian’s good friend and documentary crew guru Matt Green. I told him I was worried, but I was also concerned about pulling Damian just 4 miles before the end. It really was the toughest call. An awful lot of preparation goes in to a successful long distance fastest known time. Pulling an athlete from their run is not an easy decision. We agreed Matt would run behind Damian and verbally push him to the end, and I knew he would call me if he was worried that Damian was becoming more unwell. In retrospect, I now feel glad not to have seen the falls that I was later to hear about.
Waiting for the team to run those last few miles was one of the most anxious times I’ve had and I wasn’t able to keep my concern entirely hidden. When Damian came down the ramp to the coast, I was relieved to see him finish, but horrified to see his gait, which now looked far from antalgic. It looked neurological. Ataxic. Cerebellar.
We relatively quickly did the required photos and I grabbed some local, friendly onlookers for a lift back up to the van, as I contemplated a trip to hospital. But the improvement shortly after stopping was pretty remarkable. Even before reaching the van at the top of the hill, he was more coherent and orientated. He wrote an appropriate, albeit short message in the trail book, held by the pub at the bay, and he was able to answer my questions appropriately.
The aim of EIH treatment is to restore a normal plasma sodium concentration. In those with mild symptoms this can be done by limiting the intake of water and encouraging the eating of salty food. When symptoms are more severe, the use of small volumes (100ml IV boluses) of 3% saline can be highly effective. In those with chronic hyponatraemia rapid correction can cause brain injury. Therefore most physicians aim to increase plasma sodium by a rate of 1mmol/L per hour. It is not clear whether this should also apply to those who develop acute hyponatraemia
We got back to the hotel and I sat in Damian’s room for a couple of hours, while he destroyed a large amount of salty pizza. He was allowed some sips from a very small glass of water, principally to be able to get more pizza down. Within about an hour, he was able to recall more of his run and to talk coherently (if a little repetitively) about the previous day and a half on the trail. Eventually, I was satisfied that he was continuing to improve and was safe to sleep.
I still feel sick when I look back on this one. I am acutely aware of what could have happened and I will never attend a long distance run in any capacity without a stock cube or two in my bag at the least, and preferably a cannula and hypertonic saline. Hyponatraemia in ultra runners is, by definition an acute event. Their sodium may not drop significantly compared with the frequent elderly cohort we see in the hospital, but it drops quickly and therefore can hit harder, not giving time for the body to adapt and compensate. But the same rapid drop that can produce such threatening symptoms at least also allows us to treat the problem assertively.
The unease I felt watching Damian out on the Coast to Coast that day is now slowly subsiding. He made a complete recovery without invasive medical intervention. But the severity of the situation and the anxiety I felt during the last stage of that run are unlikely to disappear from my memory. As far as I am aware, at no point since, has Damian been able to recall the pit stop in Glaisdale, which really will haunt me for a little while to come!
Thanks Damian and Nicki for talking to me. Can I start by asking you both to paint a picture of what someone looks like (Nicki) and what someone feels like (Damian) towards the latter stages of a multi day endurance event?
(D) I guess very tired is the obvious one, usually you're sleep deprived, stressed if you're chasing a record, also pretty introspective (ie self-pitying!), and your mind gets increasingly foggy/slow.
(N) This might be an odd way of phrasing it, but it feels to me like it applies. The longer they have been out there, the more inflamed they are. They are frequently tense physically and universally depleted in many senses. There’s often a degree of cognitive deficit, many are mildly dehydrated and calorie deplete and there are a variety of musculoskeletal and foot issues that have usually caused a bit of an abnormal, antalgic gait.
As they cross the finish line, there must be a burst of adrenaline, because some bound across the line after having moved entirely less efficiently over the preceding miles. For the elite front runners like Damo, they are often moving remarkably well across the whole thing - the stiffness and hobbling setting in once they have stopped. For those at the back, the last few miles can be a persistent shuffle, having been on their feet for days. For this cohort, the finish line can bring tears of relief. And there's definitely a euphoria for all those who have met their goals.
How did this differ on the Wainwright’s Coast to Coast?
(D) It was mental and physical. I became weak, lost balance easily numerous times, especially going up steps. But I also became confused (about what we were doing) and suspicious of people (who were helping me). Normally towards the end of these record-bothering things I care a great deal about my time against the previous record, but here I lost all interested. I was confused and even a bit annoyed about people urging me to get a move on. It was like being drunk. Towards the end, when I started to run/walk "like a question mark", I was conscious of that, but couldn't seem to change it.
An abnormal gait is not unusual during the latter stages of an ultramarathon. Here's Debbie Martin-Consani moving in considerable pain as she wins the 2022 Montane Spine Race. A video of her finish can be found here
(N) Both Damian’s mental state and his gait were entirely abnormal and unusual. He has run much further than 185 miles before, with next to no sleep and without cognitive deficit. His confusion would have been comical had it not been so worrying. As he said, he tried to take off a mid layer, without removing an outer layer, and he wasn’t entirely sure why he was running.
His gait was uncoordinated and broad-based by the end of the run. What had potentially passed for a musculoskeletal gait earlier, had become neurological.
But I hope the piece of writing that you’ve published above, goes some way to showing why the description I’ve given, wasn’t obvious until the very last 4 mile stage of this race and at the finish line.
Of the many symptoms that you describe in your article what hampered your progress the most? What was the most distressing?
(D) The mental confusion is perhaps the most surprising, that I didn't care about something that I'd been obsessing over for months. My comical inability to maintain balance was surprising too.
Nicki, can you talk us through the evolution of Damian’s hyponatraemia - what were the first signs you observed? How did they evolve? Did you get the sense that Damian was aware of them? Was there a point where you were close to asking Damian to stop?
(N) The most difficult issue is that the symptoms of hyponatraemia, when mild, are not exclusive to that diagnosis. With the benefit of hindsight, there were nuances that made these symptoms more attributable to a neurological problem (and therefore potentially hyponatraemia) than to sleep deprivation / MSK issues or the like. But medics on these kind of events are also very sleep deprived and I guess it’s bound to affect the mental sophistication that we have when well rested.
In terms of progression, it wasn’t simply a case of worsening as time went on. There was a little cognitive improvement following the salty chips in Glaisdale. There were other factors that could have accounted for some of the other issues - the jostling and blood shunting contributing to the bloating, the cold causing disruption to fine motor skills, and the tendinopathy causing an initially mild, leaning gait.
I don’t think Damian had insight into his confusion but I think he was aware of the lean, just not the extent of it. I wasn’t aware of the falls and balancing issues until I saw him reach the finish line.
I did want Damian to stop when he reached Hawkser. There was something that just felt really wrong at this point and it was incredibly unnerving. But he was 4 miles from the end. It was the hardest call ever, but I think I would have been met with incredulity by everyone had I called it then. What would I do next time? The athletes I speak to about this, tell me (respectfully) that I would have been wrong to stop him at that point. Most think I’m bonkers to suggest that his fluid intake was too high and almost all feel that electrolytes would have reversed the problem (probably one of the most frustrating messages to get out, is that electrolyte drinks may have slowed dilution in the first place, but that they would have worsened an existing dilutional hyponatraemia). Most doctors I talk to are horrified that I didn’t stop him as soon as he became confused and actually become a little pale and wide-eyed when they see the finish video (although that’s also probably an apt description for me too). But medics in a hospital setting are generally aghast when I tell them of the sleep deprivation induced confusion, the gut mucosal damage and actually relatively frequently seen ‘ultra lean’ that goes along with these kind of events.
If I had this exact race all over again, with the knowledge I now have, I would stop him in Hawkser. But if with hindsight, I restricted his fluids earlier and fed him a ton of concentrated stock cube, it's likely that I wouldn't need to stop him at all!
How long did the symptoms take to resolve? Was there a point where you thought you might need further medical attention?
(D) I'm not sure to be honest. I felt roughly as expected (ie wrecked) the next day. I would expect to feel wrecked for a few days, even a week or so afterwards, but my recovery was definitely slower than usual this time around. A day or two afterwards my wife made me phone Nicki for reassurance, because she was concerned about me (and banned me from driving!).
Damian taking his final unsteady steps on the Wainwright's Coast to Coast route...
In your article you estimated that you consumed somewhere between 15 and 20 litres of fluid during the run. With the wonderful benefit of hindsight what do you think would have been the right amount? How have you used this experience when planning subsequent runs?
(D) We calculated about 400ml/hour for 39 hours, which doesn't seem like a lot to me and other experts. But for the first time I did have targets in mind rather than simply drinking to thirst. I'll go back to that approach!
There seems to be a growing awareness that anti diuretic hormone (ADH) may play a part in EIH. The hormone can be stimulated by a number of factors - pain, nausea, anxiety and drugs such as NSAID’s. Do you think this could have played a part in your experience?
(D) I had a small amount of pain/discomfort in an ankle tendon (but pretty familiar for this type of thing), no NSAIDs or other drugs (other than a tummy settling tablet of some sort Nicki gave me), don't recall nausea (which would be very rare for me). Though I was a bit burpy for a while and there were some hours when I felt a bit full/bloated (couldn't work out whether it was liquid or food – in retrospect it came on soon after some chips – high in sat fat – and this is when I cut my electrolytes) and stopped to go to the toilet a few times with little success (again a degree of constipation is normal for me during these things). Covid jab 16 days beforehand, but little obvious response to it other than a tired few days initially.
Exercise Induced Hyponatraemia (EIH) has been identified in a wide range of endurance activities. Often difficult to diagnose, left untreated it can have fatal consequences. The key is to be aware of the dangers of overhydration and emphasise to those taking part in endurance events the importance of letting thirst dictate fluid consumption.
Thanks Damian and Nicki!
"In It For The Long Run" is Damian's highly recommended account of his Pennine Way record breaking run. It is published by Vertebrate and copies can be bought here.
Comments
Leave a comment.
01/04/2022 @ 08:15:51
Very interesting read as always. Something I always try to look out for when covering endurance events and also a tricky balancing act on fluid intake weather aside . Also the amount of athletes who use NSAIDS both before prophylacticly and after events with there risk of increasing AKI and educating people in there effects...
Reply? Suspend Delete