Support May Well Be Delayed...
Posted by Jeremy Windsor on May 27, 2022
Sean Stone is a familiar face at ultra events across Scotland. As a Wilderness Emergency Medical Technician, he oversees the medical needs of athletes at events such as the Glen Lyon Ultra Marathon, Cateran Trail Race and the West Highland Way Race. We got in touch with Sean to find out more about his work. Here’s what he said…
“Back in 2002, the then race director of the West Highland Way Race, Dario Melaragni, asked if I would take my ski patroller outdoor first aid experience and ticket out to help him at that year's race. The challenging weekend stuck with me and over the years I have added further races, new qualifications, many friends and a lot of great experiences through supporting Scottish ultra marathons.
Preparations for the West Highland Way Race begin the year before, with a lot of work required in the planning stages. In addition to a request for details of their long-distance running experience, applicants receive a quite extensive questionaire on their relevant medical history which Dr Rebecca Cam and I review in every case, with an aim of establishing where significant risks might lie. The objective here is not to stop people participating, more to mitigate risks and adapt approaches to make the day as safe as we possibly can. In a few cases, we might enter discussions with the runners' own medical specialist, perhaps a runner with significant cardiac history or current oncology, to explore the extent of damage and subsequent recovery from that incident. Occasionally we might seek a temporary change of medication, especially when long term use of NSAIDs is involved. I go through this procedure for every race at which I officiate, usually 12-15 each year. Another aspect of the race community is that jointly with funding from several other Scottish races, I arrange targeted, ultra-race specific outdoor first aid courses for many of the marshals and event doctors; a clear reminder to everyone that you will be operating with minimal equipment in an environment requiring respect and an adapted approach to medicine since support may well be delayed.
The West Highland Way Race takes place in June each year. Typically, more than 200 participants take part in the 95 mile event. The record time currently stands at 13 hours and 41 minutes (male) and 17 hours and 16 minutes (female). Sean’s comprehensive briefing for the 2017 race can be found here!
At races themselves, being open minded and prepared is key, ready for whatever or whoever is going to present at your checkpoint, at the medical tent or the village hall setting you are located in. Event plans need to include options for evacuation methods and routes, contingency for an essential Highland road being blocked at the worst possible moment or a vital member of staff testing positive in the days before.
There is often a theme of the day at ultras; one day it might be several presentations of anterior tibial tendonitis in a long, slippery race or runners presenting in succesion with 'cloudy eye', an apparent corneal oedema that often ends a runner's day out.
Minor traumas, plus fractures to limbs, chest and facial injuries are commonplace as exhausted runners push on and have unprotected falls. Ultra runners are a tough lot and sometimes have to be stopped from continuing for their own good. Collapses or extensive vomiting at the finish are commonplace but are relatively usually benign; however, at the end of races we have seen collapsed lungs from an uncontrolled vaso-vagal fainting in a hotel room and a runner who fully occluded their airway when they fell unconscious in a shower. A plan to deal with a runner or supporter who develops Covid symptoms during an event is a new addition to our concerns now, with a live example testing the process at the finish of last weekend's Highland Fling ultra at Tyndrum.
Corneal edema in the left eye of a runner taking part in the 100 mile Run Rabbit Run. This condition produces painless clouding of vision that typically resolves within hours of finishing an ultra event. Further information can be found here
However, the greatest challenges to runners' health and life come from the two serious conditions which can develop; acute hyponatraemia and rhabdomyolysis. The first occasion when I met hyponatraemia was at the West Highland Way Race in 2004, with 4 cases confirmed from a field of less than a hundred runners. Two of those also developed rhabdomyolysis and were quite ill for the following week, spending days in critical care where the conflicting conditions and priorties in treatment presented a particular challenge. I would say that year by year education of the running population to avoid over-hydration has been vital in reducing the numbers now to the point where low sodium is unusual, rather than a frequent problem. We're helped by a better understanding of the hazards of marketed isotonic drinks, with many more people now realising that these are still much more dilute than you are, so they don't prevent nor mitigate for low blood sodium. After that particularly testing event in 2004, we identified that a contributing factor had been the environmental conditions, when a particularly humid 18 degrees C at 0100hrs for the race start had many of the runners loading up with fluid early on, which some never really cleared.
For a comprehensive description of Damian Hall’s experience of hyponatraemia take a look at this!
In response and over the next couple of years we investigated and eventually invested in an Abbott i-Stat analyser. This gave us blood chemistry at the finish line and as the test cartridges included creatinine kinase (CK) we could relatively quickly take a query patient across to diagnosis for either of these serious problems. However, that analyser has not been without its issues; the test cartridges have to be kept refrigerated (not usually a problem outdoors in Scotland) but the unit itself has a temperature threshold of 17C, so has to be stored and transported in a warm box. It is also very sensitive to humidity, so a constant temperature is equally important, preventing condensation forming on the internal contacts. For the last 4 years, we have also been supported by Siemens Healthineers with the provision of an EPOC Blood Analyser which I take to every race I go to.
This unit is slightly less sensitive to cold and humidity and its cartridges do not require special storage. In a remote setting or a finish line medical facility, among other factors we can now identify and monitor the progression of low sodium or raised CK, with lab standard results promoting a better outcome for patients, sent to definitive care with clear numbers and their progression. However, it does take early identification from educated first aiders and medics to get to this point in good time; urine analysis in the field can help with this, as can a visual examination of samples in the more obvious examples. The incidence of such cases varies widely and is quite unpredictable; I might not see a rhabdo for three or four races in a row, then get 4 in the same day.
Sean writes, "The priority has always been to try to create an environment where athletes can push out their very best performance, whilst trying to make it as safe as we reasonably can. We don't get everything right and continue to learn at every race…"
Hyponatraemia is, as I mentioned before, becoming more unusual but for that reason and its seriousness, you have to be fully awake to the possibility. Confusion, erratic behaviour, posture, restlessness and fluid history are all part of the picture but having access to a simple blood test within a few minutes is very reassuring, A hanging droplet of capillary blood or around 0.1ml or less is all the EPOC requires. It is sensitive to handling errors while applying the sample to the test cartridge but it has been absolutely invaluable, with both devices having made a difference to a number of athletes over the years.
Over the last twenty years, I've had the good fortune to be able to draw on the support of a strong network of outdoor enthusiasts, contributing time and expertise to the volunteer network. Specialist nurse practitioners, paramedics, GPs, hospital consultants and a consultant clinical biochemist all contribute to this network; numerous outdoor instructors help with evacuation planning and rescue resources. It's a community that together builds up to a strong and relatively safe racing environment, always looking for new volunteers happy to help feed the summer crop of midgies in the Highlands! I know that there are race directors still looking for specialist help this season, as I cannot be in two places at once. While it doesn't pay, some races can manage to contribute to expenses and there are vacancies in May and June that need covering!”
Thanks Sean and a very big “Thank You” on behalf of the many athletes that you've helped along the way!
More running related posts can be found on this blog - read about a runner’s cardiac arrest, life of the ultra runner and the fatalities in Gansu just a click away!
Don't miss Dr Nicky Lygo's description of managing hyponatraemia here! Or for something completely different, take a look at the serious side effect of Hill Billy Heroin.
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