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 39th 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.



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 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.



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.



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



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