February 2017 – The Marathon

COMRADES DOCTOR GIVES MEDICAL ADVICE

Posted on February 17, 2017February 19, 2022 by DAVE JACK

Dr Jeremy Boulter has been responsible for the medical facilities at Comrades for many years and has been involved with the facilities for the last 38 years – 2017 will be his 39^th consecutive year. I asked him how he had got involved with the Comrades medical facilities and that was the subject of my previous blog but in addition to that he gave me the article he wrote for the Pre-Race brochure for the 2014 Comrades which he tells me is as applicable today as it was three years ago and it’s certainly worth publishing on its own and given the importance of the subject here it is.

My thanks to Dr Jeremy Boulter and to Comrades Marathon Association for the use of this article.

Comrades Marathon has focused attention on the health, fitness and responsibility of runners. The following is aimed at providing advice as to what runners can do to prevent themselves from ending up in a situation where they are in need of medical attention. It is important to remember that medical attention is retro-active, ie. we only respond when a runner is in trouble. Prevention is better than cure, and the prevention of problems is in the hands of you, the runner.

WHAT CAN RUNNERS DO TO PREVENT SERIOUS HEALTH PROBLEMS?

Firstly, it is important to appreciate that runners who collapse after they have finished a race, even if they require urgent medical attention, will almost certainly recover fully. However, those who collapse during a race are most probably suffering from a serious and potentially life threatening condition. So, what can be done to prevent this latter situation from arising?

The first thing that runners can do is to make sure that they are adequately prepared. This means that they should have done enough training. They should also do their best to ensure that they have no underlying medical problems, of which they may or may not be aware. The following is a list of questions that runners should ask themselves. If you have answered “yes” to any of these questions, it is strongly recommended that you see your doctor or a Cardiologist for a full check-up before starting the Comrades.

Has your doctor ever warned you that you have “heart issues” or that you should only be physically active or do sports under medical supervision?

Are you overweight or underweight?

Is your girth over 88 cm (for women) or 102 cm (for men)?

Are you over 35 and have not been physically active for a long period of time?

During blood pressure monitoring, have you ever recorded high blood pressure?

Have you ever been diagnosed with high cholesterol?

Do you smoke or have you smoked extensively in the past?

Has anyone in your direct family ever suffered from high blood pressure, calcification of the coronary blood vessels/heart attack, blood sugar disease, or stroke?

Do you have diabetes?

In the past few months, have you had the sensation of a ‘racing heart’, problems breathing, or chest pains, whether while at rest or during athletic activity?

Are you taking any medications for high blood pressure, heart or breathing conditions?

Do you ever feel dizzy or pass out, whether at rest or during physical activity?

Do you have any problems with your musculoskeletal system, which worsen during physical activity?

Remember, any of these symptoms could be indicative of a serious underlying medical problem.

Another important point is to prepare yourself to get used to the fluids etc. available on race day. Don’t drink a fluid during training that will not be available on race day. You may well not be able to tolerate these fluids if you are not used to them. The same applies to food.

Don’t try anything new on race day. This also includes running shoes.

Do not run if you have been sick in the 3 weeks prior to the race.

A cold is different ie the symptoms are “above the neck” with a runny nose, possibly a mild sinus type headache, and a feeling of not being 100%. BUT you don’t feel really sick.

If you do run, then be extra careful and be aware of any untoward feelings and pull out. However, if you have had a temperature, generalised aching body, chest symptoms and you feel pretty miserable then that is Flu and you should not be running. Similarly, if you have needed anti-biotics then don’t run.

Do not return to training, or run the race, after illness or injury without first being cleared to do so by your doctor.

During the race be aware of any unusual symptoms that may develop eg chest pain, dizziness, severe nausea, unusual shortness of breath, change in your running style, confusion and disorientation. If this happens, stop running and seek medical attention. It has become apparent over many years that people feel it is more important to finish the race than be concerned about their health. [Or is it a matter of pride?]

DO NOT TAKE ANY MEDICATION AT ALL, either before or during the race, especially anti – inflammatories [eg. Voltaren, cataflam etc].These are commonly called N.S.A.I.D’s. They are a class of drug which reduce pain and inflammation after an injury. However they can have serious side effects. One of these is irritation of the lining of the stomach, causing an ulcer. This will cause pain, but can result in [sometimes catastrophic] bleeding. Another serious problem is the effect on the kidneys. It has been shown that NSAID’s constrict the artery to the kidney, reducing the flow of blood through the kidney and thus reducing its ability to filter waste products. Combine this with dehydration, and Acute Renal Failure [ARF] can result. This can be fatal. There are increasing numbers of runners developing ARF after Comrades, and one of the major contributing factors to this trend is the taking of anti-inflams during the race. Renal Failure is a serious condition and can be fatal.

Not only NSAID’s are dangerous. It is known that Paracetamol [commonly known as Panado] can cause Liver and Kidney damage in very high doses. Evidence now shows that it can also damage Heart muscle, causing ECG changes similar to that of a heart attack. Although these effects are usually only apparent with high doses, when dehydration is present kidney function is reduced and metabolites can build up in the body, sometimes to toxic levels. This could cause heart problems as well as affect the kidney. Anti-cramp medication can also be a potential problem. It clearly states in the packaging that they should not be taken in the presence of dehydration. When this is present problems can arise. If one considers that about 45% of the runners who come into the Medical Tent after the race are dehydrated, then one can see that taking products like these could put runners at serious risk!

PAIN!

Pain is a sign that all is not well with the body. In my opinion, any runner who needs pain killers before the race should not be running. They are not fit enough!

Pain that develops during the race indicates that some damage has occurred. It may be of a minor nature, but could be something more serious. If the pain reaches a degree where a runner cannot continue, then he/she should stop running and climb into one of the rescue busses. DO NOT TAKE PAIN KILLERS.

FLUIDS.

Ensure that you take in adequate fluids. During training you will have reached an idea of how much and how often you need to drink. Approximately 500ml per hour should be adequate. However, this is just a guide. Each runner is different. Do not simply start filling up right from the start, rather drink when you are thirsty.

FOOD.

Make sure you take in enough food to keep up with your energy requirements. Don’t try new products on race day. If you are going to take things like Goo’s, then make sure you have used them before.

My appeal to runners is that they demonstrate a great degree of self-responsibility. Take care of your health. Make sure that you are adequately prepared to run Comrades. The following is a list of the basic principles every runner should adhere to.

DO drink enough.

DO eat if necessary.

DO listen to your body.

DON’T run if you are not fit enough or not properly prepared.

DON’T run if you have been sick or on anti-biotics in the three weeks prior to the race.

DON’T take ANY medication during the race.

DON’T be afraid to bale.

Remember, the aim is to enjoy the race and finish in a reasonably healthy state. It is your body, and your responsibility to care for it! Be sensible, take note of what is happening to yourself, and make responsible decisions.

If you start running into trouble, pull out before it’s too late.

After the race it is important to make sure that you take in adequate fluid, to correct any minor level of dehydration which may be present, as well as to monitor your urine output. If you have not been passing much urine during the race it may be due to the presence of a hormone called ADH, which can be released by physical stress. If so, you will start passing large amounts of urine very soon after finishing. However, if you continue to pass very little, or none at all, late that day or night, it may be indicative of a kidney problem such as renal failure. One should then seek medical attention.

Rest is also important. Get over the initial stiffness and then start with some gentle jogging. Don’t get into any serious running too soon. Let your muscles and joints recover from Comrades!

Dr Jeremy Boulter

First Written in 2014

COMRADES PERSONALITIES

COMRADES MEDICAL BOSS – DR JEREMY BOULTER

Posted on February 2, 2017February 19, 2022 by DAVE JACK

Virtually every runner in Comrades is aware of the medical facilities offered by the organisers and they know about the Medical Tent at the finish and most know that it is the biggest temporary medical facility in a the world outside of a war, disaster or conflict zone.

Most runners also know that it’s that it’s the one place they don’t want to visit on Comrades day. The one place they don’t want to go anywhere near when they finish their gruelling journey over the almost 90km between Kwa Zulu-Natal’s two cities and especially they don’t want to be brought into the facility by ambulance from the road before they even reach the finish.

In fact they would prefer it if they leave the end of Comrades with no knowledge at all of what the inside of the Medical Tent looks like.

The Comrades medical facilities, as much as the runners would prefer to avoid going anywhere near them, form a very important part of the world’s greatest ultra road race and without the facilities offered there would be tragedy. It’s really that simple.

The man who has been responsible for overseeing in medical facilities for many years is Dr Jeremy Boulter who has been part of the medical team for the last 38 years – 2017 will be his 39^th year, and that is some going.

I had the opportunity to chat to Jeremy and I asked him about his involvement in Comrades and more specifically with the medical facilities and I started off by asking him how it all started and whether he had in fact been a runner.

DJ: How did you first get involved in the medical tent facilities to begin with way back in 1979 and had you in fact been a runner and sort of drifted into the job in the medical facility because you were a doctor?

JB No, I had never been a distance runner. At tea time one morning in May 1979, when I was an Intern at Edendale Hospital, Dr. John Godlonton asked me if I would like to help him in the medical tent at the finish of Comrades. My reply was “yes, what do I have to do?” “Oh, just put up a couple of drips on dehydrated runners” was his reply. So began an association with The Ultimate Human Race which has lasted 38 years.

DJ: It was a fairly small operation back then when you compare it to what we have now. What did you have to cater for the runners at the end of the seventies?

JB: Let’s go back to the very beginning.

In 1976 Dr. John Godlonton, a Paediatrician at Edendale Hospital in Pietermaritzburg, heard of an acquaintance who had been admitted to hospital in a state of dehydration and Renal Failure after running the Comrades. He realised that if the runner had received fluid via a drip immediately after the race, he would almost certainly have avoided being admitted to hospital. He approached the then organising committee with a proposal to set up a Medical facility at the finish to treat those runners in need of fluid after the race. This was accepted, and so the Comrades Medical Facility was born.

In 1977 Dr.John, as he was to become known by all associated with the race organisation, set up “shop” in the change rooms at the finish at the Jan Smuts stadium, now known as the Harry Gwala stadium. As far as I know, he worked alone that year, and treated about 5 runners with intra-venous fluid.

Details are a bit sketchy, partly because of the passage of time, but mainly because the medical tent, and the number of patients we had, was so unremarkable, especially when compared to the present. The tent was a 3x3m army mess tent, of the type where there was a gap between sides and roof. We had 4 camping stretchers, one trestle table for supplies, and another for belongings and refreshments.

John was present all day, but the rest of us worked in pairs in 2 hour shifts. There were six of us, all young doctors working at Edendale Hospital.

I worked two shifts and treated one patient! Our medical equipment consisted of a blood pressure cuff and drips. The intra-venous fluids were “donated” by the Edendale Hospital pharmacy. All patients who came into the tent were treated with intra-venous fluids, as the thinking in those days was that they had to dehydrated, we had not heard of over-hydration then. John’s wife, Mary was our “caterer”. She arrived with a basket containing a flask of hot water for tea or coffee, and some rolls for lunch!

To my knowledge, having a Medical Tent at the finish of a race was unique to Comrades at the time. Now it is a requirement stipulated in the rules, as laid down by ASA, at all athletics events.

DJ: Then with the retirement of the Dr John who was in charge before you, you then took over the running of the entire operation in 1996 and you have watched it grow dramatically over the years you have been in charge and it’s been in your time that the fields have consistently been over 12,000 which has meant bigger staff needed by you and you were in charge in the millennium year with the biggest ever field at around 20,000.

JB: Over the years the tent grew in size as the number of Comrades runners grew, and thus patients, increased. We moved from somewhere in the centre of the field to the side, adjacent to the track just before the final straight. We were able to sit outside our tent and watch the runners coming past us. It became a game amongst the doctors to watch these athletes as they struggled past in varying states of exhaustion, to predict who would be coming to visit us in the Tent. We were seldom wrong! Then we were moved to an area behind the stadium, as we had become too big and took up too much space inside it.

Sometime in those early years, our “Medical I.T.” section was born. This was a system to inform the public which runners were in our tent. It consisted of a blackboard at the entrance to the tent, on which the patients’ race numbers were written in chalk. When discharged, the number was simply rubbed out. A far cry from our current set up, where we have laptops linked to the information tent and the main Comrades data base!

We have also introduced a mini laboratory into the tent. This enables us to have vital blood parameters of our patients, such as blood Sodium levels, available within a few minutes, which have a direct bearing on the treatment.

DJ: How do you know the numbers you need in terms of specialists and doctors, nurses, etc. You told me previously that you have a three bed ICU section in the medical ten. Is that just a guess and a hope that it’ll be enough or do you look at different requirements on the Up Run versus the Down Run?

JB: The staffing of the tent has grown year by year as the size of the field has increased. We treat between 2 and 4% of the field, so I know roughly how many patients we’re likely to have and so how many beds and doctors we will need. We currently have about 40-45 Interns, 20 Medical Officers, 8-10 Specialists and about 20 nurses working in the tent, as well as the mini-lab and admin staff.

The ICU size is essentially governed by availability of space and essential equipment. Is it enough? It has to be!!! Whether up or down, our preparation is the same, and there is not really any difference in patient numbers or the type of problems we see.

DJ: Are you responsible for the medical staff who are out on the road as well and are you in touch with them? So in other words if there’s a runner who is in trouble and is picked up by one of the ambulances do they contact you for instruction based on what they find?

JB: Yes, I am responsible for everything Medical to do with Comrades. We have a medical JOC adjacent to the tent, which is in control of, and in contact with, all the ambulances, rapid response cars and personnel out on the route. I can communicate via radio or cell phone with them if necessary.

DJ: Is there a team making the decisions when you have a seriously ill runner or does that all fall on your shoulders alone as to whether this case is hospital or worse – ICU or not and that one can be treated in the facilities you have and discharged.

JB: Yes. The specialists are each allocated an area of the tent for which they are in charge, and they make all necessary decisions for their section. Obviously if there is a complicated case, then other specialists and I will be involved in the consultation and decision making.

DJ: I’m going to put you a bit on the spot now. How much of what you see in the medical tent do you think is caused by inadequate training where the runner has simply not done enough?

JB: I think the level of training plays a part in the “state of exhaustion” of our patients, but not so much in the “medical problems”. Let me explain. Everyone is going to be really tired and sore after running 87km! The degree of suffering will be directly related to the amount of training and fitness of the runner. However, the serious cases we see are almost invariably due to runners taking part when they are unwell, or have been ill shortly before the race, have been inadequately hydrated or [probably the most serious] have taken medication [eg analgesics and anti-inflammatories] during the run.

DJ: Where in the field in terms of time, do most of your customers to the medical tent come from?

JB: 80% of the field finishes in the last 2 hours, and that’s when we get hectic! We quite often get runners coming into the tent up to 2 hours after the final gun!

So there you have it. Should you have the misfortune of ending up in the medical tent you can rest easy knowing that you are in good hands with Dr Jeremy Boulter and his team of around 85 trained medical staff ranging from specialists to nursing sisters with an ICU section and ambulances out on the road.

My biggest wish is that on the 4^th of June you don’t get to meet any of these really nice people.

February 2017.