WS Run Ask-a-Medic

Catcher in the Eye

noreply@blogger.com (Linda Lee) — Mon, 19 May 2008 00:04:00 +0000

The most common eye emergency that is encountered during a trail running event is; “gunk in the eye”. There is so much dust and so many miles, that debris gets into the eyes. The best protection to prevent eye injury is to wear protective lenses. (UV protection for the rays and a barrier for the dust). The cornea is a domed layer of clear tissue over the iris and pupil. It is full of nerve endings but has no blood vessels, so it gets oxygen directly from the atmosphere and nutrients from tears. The conjunctiva is a thin transparent tissue covering the surface of the eye. It starts at the edge of the cornea and continues to cover the undersurfaces of the lids. Inflammation of the conjunctiva is often called, “pink eye”.
If there is debris in the eye, then it rubs back and forth onto the sensitive cornea. This causes a scratch (corneal abrasion). Because there are so many nerves in the cornea, there is PAIN and a sense of a foreign body in the eye. The diagnosis can be made with an orange stain of the eye and a cobalt blue light. The stain is taken up by the scratch and is seen clearly with the blue light.

Allergies may cause itching, tearing and a sense of filmy vision or a gritty feeling in the eye. The conjunctiva can swell causing a jelly like appearance to the eye, and the tiny vessels dilate causing a pink hue. Those persons who know that they have allergies often take antihistamines prior to exposure to environmental aggravators. Oral antihistamines are NOT recommended during WS because they are one of the drugs that effect heat regulation. A topical eye drop (mast cell stabilizer) prior to the exposure helps to prevent the response.

Another eye emergency that can happen when there is bright sun light and reflective snow is, “ultraviolet keratitis” commonly known as snow blindness. The risk for UV Keratitis increases as one goes up in altitude. Snow blindness is extremely painful and represents defuse damage to the cornea. We have not seen this at WS. It is treated with eye protection, topical antibiotic ointment, rest, and pain medication.

Kami Semick had a question about corneal edema (inflammation) in response to the elevation at Western States. The barometric pressure at this elevation is about 550mmHg as compared to 760mmHg at sea level. As the tension of oxygen drops with an increase in elevation, the cornea may not get the oxygen it requires. There has been a reported case at 9000 ft. after the person previously had radial keratotomy. It is suggested that this phenomena requires more than 6 hours at very high altitude to develop. I wonder if Kami is the second case study at this elevation?

At the WS aid stations we will have saline if needed to rinse eyes. We will not have any eye anesthetics, allergy drops or eye antibiotics. Remember to wear eye protection and be prepared for the unexpected. You may be the wild card.

Left, right, left, right,
Linda

Wool Blankets

noreply@blogger.com (Linda Lee) — Thu, 24 Jan 2008 15:52:00 +0000

I'm looking to stock up the supply of wool or synthetic fleese blankets for our aid stations. If you have any to donate, please bring them to Way too Cool or to AR 50.
Thanks ever so much!

And just a thought. Do you think anyone in our sport is using preformance enhancing drugs? Some of these same drugs are being used for anti-aging...... As I sip on my preformance enhancing Peets coffee, at the age of 52.

Left, right, left, right. Linda Lee
High Sierra country.

Talk to me, Babe

noreply@blogger.com (Linda Lee) — Wed, 28 Nov 2007 20:12:00 +0000

I like to think of this blog as a medical consultation. No appointment necessary, no white coat, and the opportunity to explore issues related to the run and your health.
If you hit this, read this, please comment! I want keep it up and ‘running’.

I was fishing through an old blog and found a great question that I never responded to.
It was written on 6/26/07. Isn’t that two days after the race? So, I would like to address this question now, and ask that you also go back to read the blog on altitude sickness.
Marti said “I have always heard that if you can’t get there several weeks ahead to acclimate, that you should run your race within 3 days of arrival. Can you say more about your recommendation?”

There is an INITIAL acclimatization to altitude and there is the LONGER TERM acclimatization that occurs over weeks. Again let me say that the initial response to altitude is based on rate of assent, absolute altitude and individual predisposition. The physiologic response is very complex. In the initial response, ventilation increases in response to hypoxia. This blows off the carbon dioxide and results in an alkalosis. Then the kidneys kick in to correct the alkalosis by excreting bicarbonate. This happens in the first 24-48 hours. There is a 12% reduction in plasma volume in the first 24 hours (your peeing it off) and the heart rate and the blood pressure go up. Also, the pulmonary artery pressure goes up. The blood flow to the brain increases and returns to normal in 3-5 days. The long term acclimation over weeks is the development of an increased red blood cell mass and improved exercise tolerance.

Arrival the day before the event is adequate, although AMS may be a problem. The headache is an unpleasant symptom and accompanied by nausea, fatigue and sluggishness, …. NOT my ideal way to start a major race. The symptoms of AMS have been described as feeling like a hang over.

The WS race peaks at just under 9000 feet, but if I was one of the 20% of persons who will get AMS, I would opt to stay in Tahoe for 3 days prior to the race, before I climb an additional 2500 feet.

Hope you’re out there Marti and I hope I answered your question.

Left, right, left, right,
Linda Lee

Welcome 2008 Runners

noreply@blogger.com (Linda Lee) — Fri, 16 Nov 2007 13:55:00 +0000

I’m getting pumped up about the up-coming lottery and the months prior to the 2008 Western States! I understand that there are a record number of entrants, indicating the growing popularity of ultra running.

My mission as medical advisor is to provide accurate medical information to you, the runner, the staff of volunteer medical providers, and the trustees. I enjoy the “hands on” approach. This year started with stocking the medical supply boxes for each of 10 medical check-points. Assessing possible needs combined with practical supplies, we make every effort to be prepared for the unexpected. Last year, we started the ‘Ask a Medic’ blog, posting topics related to health, possible injuries, metabolic abnormalities, and environmental conditions. Education is the best way to prepare a runner for the unexpected.

The Western States trail is both magical and diverse. There are extreme changes in elevation and temperatures. The wilderness areas are home to many animals including black bear, cougar and rattlesnake. The trails are steep, rocky, sometimes snow covered, dusty, or slippery with oak leaves. It is a tough 100 mile race! Not only does the participant need to be physically ready, but also there should be a high level of self- reliance. Knowledge is power. The more you learn about the trail, how to take care of yourself and how to recognize when you are in trouble, the closer to success you will come.

With every effort, each medical volunteer will assist you to that goal, bandaging blisters and nursing an upset stomach. In the case of severe illness or injury, we will do our best to stabilize and transfer you to appropriate medical care. Please remember that much of the trail is inaccessible to vehicles and helicopters can only land in acceptable landing zones. I encourage you to buy the flight insurance, should an accident occur and air transport is needed.

I will be available from now until the race, through the blog. I will be at the Michigan Bluff aid station during the training weekend and on race day. And yes, my favorite place is the finish line, brimming with joy for every one of you that accomplishes this phenomenal event!

Left, Right, Left, Right,
Linda Lee MPAS, FNP-C

Genus; Crotalus

noreply@blogger.com (Linda Lee) — Fri, 01 Jun 2007 17:07:00 +0000

Rattlesnakes. There are 45,000 snakebites annually in the United States. 7-8,000 of these are considered venomous. 12-15 deaths occur each year. A rattlesnake’s primary defense is avoidance. They are nocturnal feeders and during the day can be found under brush and rocks. They rely on camouflage. When alarmed, they coil and shake their rattle. If a pit viper strikes a runner, it will most likely be on the lower extremity. 15-30% of crotalid bites will inject no venom at all!

If a snake should bite you, determine if it is dry or venomous. Pain and local swelling is the first sign of envenomation. This can advance to rapid swelling of the entire extremity, blisters with blood in them, and bruising and broken vessel appearance. Systemic affects include, tingling of scalp and twitching of the muscles around the eyes. Weakness, sweating, nausea and dizziness may occur. A minty or metallic taste may ensue. A person can get very sick or have incredible disability or need for amputation from a rattlesnake bite.

If you run alone, let someone know your itinerary. If you get bit, and have an envenomation, stay calm. Keep the extremity lower than the heart and immobilize. Take of any jewelry off. Place a bandana or something similar in a fashion like a tourniquet. Not so tight, just enough to decrease lymphatic flow. Drink lots of fluids. Use your cell phone to call 9-1-1, or send a companion to get help.

Rattlesnake bites are not benign and require rapid transport to an emergency room where antivenin can be administered. If you should ever receive a venomous bite during the WS 100, notify the nearest aid station to help with evacuation.

Acute Mountain Sickness

noreply@blogger.com (Linda Lee) — Tue, 24 Apr 2007 01:56:00 +0000

There is a mention of high altitude illness in the Western States manual of possible medical emergencies during the race. I would like to take a moment to educate you on the PROBABLE occurrence of this event.

There are three terms common in describing high altitude illness. The first is Acute Mountain Sickness (AMS). A progression of this neurological event is High Altitude Cerebral Edema (HACE). The third term is High Altitude Pulmonary Edema (HAPE). This phenomenon is due to the rate of ascent to altitude and the absolute altitude reached. I will not discuss the pathophysiology of AMS, but give you some statistics to further your knowledge.

The highest point in the Western States Endurance Run is 8750 ft. The race starts in Squaw Valley at 6200 ft. During the first five miles of the run, a gain of 2500 ft takes place! Some entrants fly from sea level and drive up to the start immediately prior to the race.

20% of unacclimatized persons will develop AMS at 7000-9000 ft. (1850-2750m)
Higher prevalence in persons under 50 years of age, children equal to adults.
Physical fitness is not protective against high altitude illness.
Persons with previous AMS have an increased risk of getting it again.
Rate of ascent, altitude reached and individual physiology, predispose one to AMS.

Typically the symptoms develop within 6-10 hours, but sometimes as early as 1 hour. The hallmark is headache accompanied by any of the following; gastrointestinal symptoms (nausea and vomiting or loss of appetite), inability to sleep, dizziness, fatigue and sluggishness.

Given the number of race entrants from sea level, this is not a trivial problem. HAPE commonly occurs on the second night and for the time in the high country it is doubtful. HACE is a medical emergency and a progression of AMS, also doubtful due to the absolute altitude of the Western States trail, and the duration of time at this altitude.

Wilderness medicine reviews will advise a drug called acetazolmide (carbonic anhydrase inhibitor) for prevention of AMS. DON’T DO IT. It is a diuretic and can cause changes in the potassium sodium balance. It causes a bad taste in your mouth, tingling and numbness of hands, and dizziness. PREVENTION is the key to not developing this illness.

Acclimate for three nights at Tahoe prior to the race.
No sleeping medications or alcohol.
Encourage good hydration and high complex carbohydrates.

Again, this is a brief summary of a complex and progressive illness. I hope it sparks questions and discussion.

Linda Lee

Burr, it was Darn COLD

noreply@blogger.com (Linda Lee) — Mon, 16 Apr 2007 00:43:00 +0000

Yesterday heralded the running of a very wet, cool and cloudy American River 50 Mile run. The weather channel predicted it. Prior to driving north to Auburn from Yosemite, I packed the car with my essentials for a day of Medical Aid at the finish line.

The problem for the day was HYPOTHERMIA. Hypothermia essentially means, “too cold to rock and roll”, or a core drop in temperature of 3.6o F. Accidental hypothermia occurs in healthy individuals with simple environmental exposure. Three degrees is not much of a drop, but it is enough to get you in trouble on the trail. And it just gets worse as your temperature falls farther and farther.

It was towards the end of the run when we started to get our REALLY cold runners. That is to be expected. These are the folks out there the longest, and are not in the elite physical condition as the top runners. One participant was from Texas where the weather is hot. She was not acclimatized to the sudden change in weather.

Humans have a basal heat production of 50m2 BSA/hour. It is increased with eating, fever, activity (running) and shivering. It is lowered when the runner is in a cool climate, fuel depleted, fatigued, and dehydrated. Cold and exhaustion is the common denominator for accidental hypothermia and it DOES NOT take an extremely cold temperature to produce hypothermia after energy depletion.

Aid station personal or other runners can recognize trouble on the trail. I worry about it during nightfall and the wee hours of the morning at Western States.
Besides being cold and shivering, the runner may exhibit amnesia, inability to find the right words, poor judgment, anxiety, or become apathetic to the circumstances.
As the pendulum swings farther towards lower body temperatures, the person becomes stuporous and body functions decline.

Accurate measurement of core temperature is impractical for field treatment of hypothermia. Correction is essential! A field impression can be made by the circumstances of the discovery, duration of the exposure, predisposing conditions, and don’t forget any associated injuries.

If the person cannot swallow, and their mental facilities are severely compromised, activate the emergency medical services. Otherwise, strip the individual of ALL wet clothing and shoes. Dry and insulate. Wool, synthetics, space blankets or plastic bags will keep the heat in. Layer. There is NO ROLE for cotton. Cover the head. Hot packs (chemical pads or hot water in Nalgene bottles) should be placed in the armpits, groin, and on the neck. Heat the Core. Feed the runner hot cocoa, tea, hot Jell-o, or hot Tang. If you can, turn on the heater in the car, and allow the ambient heat of the vehicle to assist. If sitting on the ground, provide a pad or some type of insulation.

Prepare for bad weather. Use drop bags. Have dry clothes placed accordingly. I just touched on the topic of hypothermia. Physiologically it gets very complicated, but recognized early on, and corrected appropriately will save the runner from spiraling downward.

Right, left, right, left. Linda Lee

All those L-O-N-G miles in the sun

noreply@blogger.com (Linda Lee) — Fri, 06 Apr 2007 17:13:00 +0000

We are all concerned with premature aging and skin cancer. The anti-aging industry is skyrocketing and the dermatologists have more work than they can keep up with. Every time I go to my dermatologist, I am told to stay out of the sun, especially between the hours of 10:00 and 3:00. Yah, right!

Ultraviolet (UV) radiation is invisible light waves that are shorter and more energetic than visible light. UV radiation is subdivided into categories based on wavelength. UV-B (320-290nm) and UV-A (400-320nm) are the two of greatest concern. UV-B causes sunburn, helps with Vitamin D synthesis, and is responsible for skin damage causing photoaging and cancer. UV-A is approximately 20 times more abundant, is not filtered by window glass. UV-A is unaffected by atmospheric conditions and is 100 times more likely to cause havoc to the skin. UV exposure is the primary cause for basal cell and squamous cell carcinoma! Sun exposure also increases the risk of developing melanoma. UV radiation directly damages cellular DNA and suppresses the skin’s immune system.

Besides wearing cover-up protection, sunscreens are needed for skin protection. Pick a chemical absorber or a physical blocker. Make sure that it is protective against the UV-B and the UV-A wavelengths. Apply generous amounts to all exposed skin and reapply every few hours.

I will be at the finish line of American River 50. I may see you there! Run safe, run wild, stay upright and mobile.

Linda Lee

Risk for Hyperthermia

noreply@blogger.com (Linda Lee) — Thu, 08 Mar 2007 00:22:00 +0000

While we are on the topic of medications, I would like to raise attention to the antihistamines, phenothiazines and tricyclic antidepressants. These medications have anticholenergic properties and can be dangerous in the setting of a hot environment. They can increase the risk of hyperthermia. Hyperthermia is a life-threatening emergency.

Simply, an anticholenergic drug blocks the parasympathetic nervous system. The parasympathetic nervous system will increase sweating, salivation, gastric mobility, slow the heart rate, and constrict the pupils and aid in urination. When you block this system to excess, the opposite occurs. If you cannot sweat, then you loose your ability to cool your self.

The most common of these drugs is the antihistamine diphenhydramine, (Benadryl)! I keep Benadryl in my medical aid pack and it can be a life saving drug for a severe allergic reaction. It also can help with motion sickness and nausea. Benadryl is an active ingredient in over the counter sleep aids and cold preparations. Many people treat their own symptoms of allergies with one of these medications. There are also the newer selective preparations like Clariton, Clarinex, Allegra, and Zyrtec.

The well-known phenothiazine is prochlorperazine maleate (Compazine). This medication is given to adults for nausea and vomiting. A similar drug is metoclopramide, (Reglan). Promethazine (Phenergan) is also commonly prescribed for nausea and vomiting. These drugs also have anticholenergic properties and can predispose a person to hyperthermia.

Although the tricyclic antidepressants are an older class of antidepressants, we frequently prescribe them for other mood disorders, chronic pain and as sleep aids. Not only do they cause a dry mouth and decreased gastrointestinal mobility, they increase heat production by decreasing the sweating mechanism!

If any of these medications ring a bell for you, please think twice prior to using them in any arena that places you at risk for hyperthermia. There are alternative solutions for hay fever and allergies. Nausea and vomiting may not be completely diverted in ultra distance running, but eating and hydrating strategies can certainly help reduce the incidence.

I will return on March 18th from a ten-day medical mission to Guatemala. Keep training. Right, left, right, left.

LLee

Introduction by Linda Lee, Nurse Practitioner

noreply@blogger.com (Webmaster) — Wed, 28 Feb 2007 01:28:00 +0000

Welcome to the running of the 2007 Western States Endurance run!

My name is Linda Lee and I am thrilled to be the medical advisor to this prestigious event. I am a Nurse Practitioner with a background in emergency and wilderness medicine.

I would like to introduce this informal, interactive resource to the existing WS100 web site. In the upcoming months you will be increasing your miles as well as fine-tuning your training strategy. With this, come the occasional ache, pain and minor injury that can interfere with your plan. You will want to know about heat, snow, altitude, electrolytes and possible environmental emergencies that can occur on the WS trail. As the anticipation of the run grows with each day, I hope to relieve some of the stress by providing available medical information.

High Blood Pressure affects over 60 million people in the United States. The diagnosis is defined as a blood pressure of 140/90. Overall, HTN (hypertension) is more prevalent in older age groups (over 40). HTN remains a major public health burden. Despite the rigorous exercise schedule of ultra runners, you are not immune. I encourage each runner to have a screening medical exam prior to taking on such a physically demanding endurance event.

There are different classes of blood pressure medications, one being the Beta Blockers. These are the drugs that end in “lol”. Common drugs in this class are metoprolol, atenolol, labetalol, and propranolol. If you are one of those on an anti-hypertensive medication, check to see if it is beta-blocker or one of the combination drugs.

Beta-blockers are competitive inhibitors of catecholamines at the beta-adrenoreceptors sites. B1 receptors are found primarily in the heart. B2 are found in the heart but are most prominent in the bronchial and peripheral vascular smooth muscle. So when the beta-receptors are blocked, there is a slowing of the heart rate, and contractility. Rather than dilation of the bronchial, and peripheral vascular smooth muscle, there can be a side effect of bronco-constriction. The blood flow to muscles can be reduced.

What this means to an ultra runner is that when you have to climb out of El Dorado Canyon, you are not able to increase your heart rate to meet the demand of the exercise. Your legs may feel sluggish and some people wheeze. You loose the capacity to exercise to your full ability!

Although beta-blockers can be excellent anti-hypertensive medication, and are very useful in certain kinds of heart failure and heart attacks, they can cause a lot of problems for the athlete.

Another anti-hypertensive drug that is counter-productive in an extreme athlete is a diuretic.

Hydrochlorothiazide is one of the first line drugs for HTN. It does not make sense to use this drug because it can add into the effects of dehydration and electrolyte disturbances during the endurance running events.

Good communication with your health care provider can facilitate fine-tuning your blood pressure. Never just stop your medication, but rather explore the alternative anti-hypertensive that does not have an effect on exercise tolerance.

-- Linda Lee, F.N.P.