Ironman triathlon

With two triathlon agegroup world championships under my belt, I decided to mark 10 years of competing in triathlon by signing up for an Ironman in July 2006: 3.8km swim, 180km cycle and 42km run. It turned out to be a far more challenging day than I could ever have imagined.

The race

The race took place outside Zurich, Switzerland. It was hot, reportedly 3537C. The swim went quite well, given the difficulties of establishing the correct pace when surrounded, as I was, by 1,800 competitors. I finished in 60 minutes.

Next came the cycle: three laps, with three climbs per lap. I aimed to complete it in six hours, leaving some reserves for the marathon. Lap 1 went well, though a bit faster than I’d planned, at 1hr 52min. Then, halfway round Lap 2, at the foot of the main climb, I experienced stomach cramps. I tried to figure out the cause and what I should do:

* Are my extrapadded new shorts too tight at the waist? No.

* Have I been eating and drinking wrongly? No, I’ve followed my normal regime.

*Are the race conditions proving too much for my digestive system, what with the heat and the added psychological stress?

I know that cramps can happen if the stomach has too much concentrated energy/solids in it. So I thought I’d drink water for the next while to dilute the contents and see if I’d bounce back.

The cramps persisted. I carried on riding, periodically altering my position on the seat, rubbing my stomach, pouring water on myself to try to stay cool, drinking a bit more water, and after a while trying to eat to top up my calories. I had to force down the food, sugary drinks and energy gels.

With about 40 minutes of the cycle ride to go, I stepped off to have a pee and spent a minute or so rubbing my stomach and stretching, with no improvement. I knew I was slowing – although less than I perceived at the time. I really wanted to clear this gastric discomfort before the run. Otherwise I might end up walking, and 26 miles wasn’t a distance I wanted to walk!

As I started the run I decided to take it steady, find a pace that I could sustain and see what happened. My original plan had been to take fluids in at every water station (1.25km) and an electrolyte gel every 2530 minutes. But now, feeling nauseous, I really didn’t feel like taking in the gel.

The run was four laps and my goal was to finish in four hours. I completed lap 1 in 55min, including loo stop (where the sauna conditions added to my nausea). Concerned that my mind was becoming confused, I made a great effort to think strategically, calmly and with focus:

‘Take it easy. Relax. Run economically. Is there any tightness in my body? Yes – OK, then stretch out as I run. That’s fine. I expected niggles. It’s been a long day. I’ve never done a marathon before. I can do it. Keep going. Try for the four hour target, but keep it steady. I’m slowing. OK, do what you can. Follow the strategy. Run in the shade as much as possible. Relax. Keep going. Don’t walk as you might not start running again. This is probably the only Ironman I’ll do. You’re doing well.’

On lap 2 I slowed to 65 minutes, and by lap 3 had dropped to 75 minutes. The final lap was a struggle, but I finished with a 4:28 marathon and an overall time of 11.41.

Breakdown

Once I’d crossed the finish line and stood still, I felt worse. My head was spinning and balance was difficult. I thought a drink might help and chose cola, believing the fluid, energy and caffeine would help. Within 30 seconds I vomited nine times, bent over double. Even in my hazy state, I was surprised at the volume that came out. I stayed bent over until someone offered help and walked me to the medical tent. There, they hooked me up to a drip. I was feeling so rough, I just wanted to lie down.

My memory of what happened next is less clear. I lay relaxed, mostly sleeping. After what was probably an hour, a medic asked how I was feeling and was I ready to leave? I replied that I was feeling very rough, my head was spinning and I was very tired. They gave me a second drip and took my blood pres sure. At some point I got up, drip in arm and medic in tow, to use the loo. I felt truly dreadful and was becoming concerned.

Again, the drip finished and the medics asked how I felt. Again I repeated my symp toms and said I wasn’t ready to leave. I was also cold by now. They gave me a blanket and a third drip.

Shortly after this, I recall a group of medics quizzing me sternly and insisting that I should make an effort to get up so that I might leave. I said I felt reallybad, with everything spinning and lightheaded. But I gave it a go, with a medic at each arm. As I straightened, everything went dark.

The next thing I know, there’s an object in my mouth. I drift in and out of sleep. Someone’s rubbing my forearm. A clock shows 3:45, is that morning or afternoon? A nurse is telling me I’m in hospital. What is this in my throat? Can I be on a ventilator? The nurse tells me I’m on a ventilator. I’m an Ironman. She points to the drip stand with my finisher’s medal on it. She points to a photo: do I know who it is? I nod, thinking it is me, but my eyes are fuzzy. It turns out it isn’t me but my partner, also competing. The nurse says they will take me off the venti lator in a few hours to see if I can breathe on my own. She says I’m doing better. Better? How bad had things got? I’m told it is Tuesday morning. What’s happened in the last 36 hours?

At 8am, a doctor arrived. They pulled the tube out of my throat; then removed the catheter. Apparently I had passed out after three hours in the medical tent. The hospital thought my heart had slowed to 510 beats per minute. Their main concern had been that my lungs were filling with fluid. For quite a while they didn’t know what was happening. My sodium levels were very low, so my system started to fail and I had developed pulmonary oedema.

Off the ventilator, I was transferred to a lung ward, given some breathing apparatus and the goal of reaching 3.5 litres of inhaled air. My first four attempts reached 750ml. My lung function was so compromised that even turning in bed from my back to one side left me gasping. I had become so weak that even lifting the jug to pour water into a glass was impossible. I had to use both hands and lean the jug over. On the bright side, my appetite was good; at least my stomach seemed fine.

I felt extremely bruised and sore around my shoulders. For the next five days I coughed blood, in steadily reducing amounts.

In the afternoon of day 5, I was let out, with a discharge letter listing my diagnoses:

1. Heatstroke and dehydration after a triathlon:

– generalised tonicclonic epileptic seizure

– with hemodynamic instability

– with hemorrhagic pulmonary oedema (intubation and mechanic ventilation)

– rhabdomyolysis

– hyponatremia, anemia, low Quick

2. asthma

3. reduced ejection fraction of approximately 40%, cause unknown.

Some weeks later, a gastroenterologist suggested that I’d experienced exercise induced gastric ischemia (reduced blood flow) that probably led to the valve below the stomach closing. This meant that little food or fluid made it through to the small intes tine where it could be absorbed.

This meant I would have been sweating out more fluids and minerals than I was replacing. This would cause cramps, either as a product of the reduced blood flow or because of the stomach stretching with the food and drink I was forcing down, and my markedly reduced interest in taking in food or drink.

Recovery

My travel insurance company sent out a doctor from the UK and gave me oxygen for the flight home. Once back, I continued to use the breathing apparatus every hour or two. After a week I was hitting 3.5 litres regu larly. From the first day home I settled into a daily routine of going for a midmorning walk. In a week I built this up to a mile. I quickly learned that twothirds of the way round I needed to stop and sit for 2040 minutes to regain some energy. If I acci dentally overdid things, I would feel a wave of fatigue that I could only liken to a very heavy flu, the cue for me to sit immediately to avoid collapsing. This was a feature of my recovery for the first month or so.

Within 10 days my lung function had recovered to normal. By the end of the first month I was walking for 1 2.5 miles in the morning about four times a week. Some days I included hilly streets to work my body a bit harder. Once or twice a week I’d ride my mountain bike for 1025 minutes.

After two and a half months I went to the hospital for an ECG and transthoracic echo (an ultrasound of the heart). My heart appeared normal. On hearing this news, I asked to be hooked up to a 24hr ECG and put myself through my own maximal exer tion treadmill test I needed to know that my heart really was sound. Having completed this with no illeffects, I felt happier to push on my rehab to include some tougher work.

Lessons

Seven months have passed since my Ironman event and the start of my postrace recovery challenge. I’ve been back at work for three months.

Here are some learning points from my experience that might be useful for those who work with injured athletes:

* In endurance events, the warning signs that something dangerous or bad is happening to the body won’t always be dramatic (eg, fainting, severe pain). Sometimes they can be overridden by determination and dogged ness. I accepted before and during the event that I might need to pull out, but because I was able to keep going, I just did.

* During my recovery I found I was often very poor at being able to interpret what my body was telling me. Was I feeling normal fatigue, sluggishness because I hadn’t done much recently, tiredness due to illness, or idleness? At other times it was more obvious: when doing some exercise I would become slug gish and my mind dominated by thoughts of lying in bed. At these times, the best thing was to head for home within 1015 minutes. I’m not sure how professionals can advise on this, as it makes it hard to prescribe a simple progression in rehab exercise.

* I went through a range of emotions after my neardeath experience. For me, these were mainly anger and frustration about what had happened. There was some relief, of course, that I’d survived, but not joy. I was angry that the paramedics had, in my mind, either accel erated my deterioration or caused my system failure by giving only water and glucose, but no electrolytes. This diluted what little body salts I had, leading to heart failure and pulmonary oedema. I was angry that no one in the tent made the effort to ask me what had gone on in the race, what I had eaten, drunk or felt, or why I finished with plenty of unopened electrolyte gels on my belt. But then, these same medics had saved my life, too.

* I had to face further psychological trauma and challenges well after the hospital experi ence. For instance, three weeks after I returned home, I received an ambulance bill that also covered medical tent expenses. It itemised defibrillation pads, gel and charging; adrenaline injection; and 15 minutes of CPR. Up to that point I had thought that my heart had only slowed. I hadn’t realised it had had to be jumpstarted or needed so much extra help. This news was difficult to absorb.

* Fear was another dominant emotion: What if something similar happens again? What if there is some lasting damage? What if there is a weakness in my heart? Are the sensations in my chest that I now notice something to worry about, or do I notice them only because I’ve become hypervigilant? What if I’m out without my mobile or alone and something happens? For me, it was best to evaluate these thoughts rather than ignore them or become obsessed with them.

Looking ahead

My energy still varies throughout the week, though the dips are less low. I’m swimming, cycling, running and doing some gymbased strength work, probably at about 60% of the volume I’d expect at this time of year. In the past month, I’ve undertaken some swimming (400m) and running (5K) tests and my times are close to what they’ve been before, so this is encouraging. I have just been told my 24hr ECG seemed normal, but I’ve been referred for a further checkup with a cardiologist.

I hope to do some triathlons this year, and if training is consistent and things work out, I plan to try to qualify for the Triathlon Age Group World Championships in 2008.