Tuesday, December 28, 2010

Doctor: I Have My Laptop, Do I Need To Talk To The Patient, Too?

Electronic Health Information - EMR or EHR

There’s a revolution going on. Slowly, medicine is shifting from paper based medical records to a computer-based system that’s likely going to impact you. Currently about 15% of hospitals and physicians have made the switch to electronic record keeping. The rest still use paper as has been the standard for decades. However, despite their familiarity, there can be drawbacks to using paper. Handwriting comes to mind immediately as I’m sure you know the old saw about doctors and legibility. Also, think about a chart that’s 3” thick from a patient who’s had the same doctor for many years or a couple significant illnesses. And, if you want this information transferred to your new physician when you move, but the original chart stays put, it can prove problematic. Culling specific test results from a chart like that can also be challenging.

In 1999 it was estimated that there were as many as 98,000 medical error related deaths annually in the U.S. A measurable percentage of those were caused by errors in medical record keeping or retrieving previously obtained information be it from physicians, pharmacists, nurses, lab personnel, etc. That said, as you’d expect the electronic record has its drawbacks as well, some of them quite significant. Anything that can happen to computer based files, good... and bad as we see frequently in the media, could potentially occur to your private medical information. This risk is present despite encryption, passwords, etc. (Think Julian Assange – WikiLeaks. Think about the big information loss that the VA system had a few years ago.)

As you might imagine, the change over is anything but free. I’ve read that it can be as much as $40 - 50,000 per physician. Then there’s a pretty steep learning curve where the doc has to cut his/her schedule in half at least short term limiting access. The top of the medical diagnostic team becomes the transcriber as well , oftentimes never really regaining the current level of efficiency.

And the personal nature of paper, little notes you leave for yourself, specific to each particular patient, like to say thanks again for the brownies they brought you at the last visit, seems to be lost with computerization. On the plus side, overall staff needs will decrease over time. The American Recovery and Reinvestment Act of 2009 provides an incentive to make this change and eventually those physicians who’ve chosen not to adopt EMR may be penalized up to 3% of their Medicare reimbursement as early as 2015.

As I write this, my wife’s practice is in the middle of this change. They enter the exam room, computer in hand, and some patients note that, “The doctor spends more time looking at the computer than me.” And they’re right. But to even get to that point, the doctors are spending endless hours, working well into the night, and sometimes into the very early morning, to get that patients labs, medicines, x-rays, notes, etc. into the electronic document for that days visit. Yep, there’s stress on both sides of the white coat.

So, we’re a system in transition. And change, any change, is often uncomfortable. But as doctor and patient both get used to “the new way’” advantages will become apparent, errors will hopefully continue to decrease and the quality of care, your care, improves steadily. And, anything you can do to help is most appreciated!

Old Kona Surf Hotel, T-2 and Carbo Dinner site.  Now the Sheraton. 

Tuesday, December 21, 2010

Ever Seen Blood In Your Urine? It's Could Be Runner's Bladder

Hematuria, blood in the urine

"Oh yeah, life goes on, long after the thrill of livin' is gone."  John Cougar Mellencamp

But Lew Hollander, yellow cap, would say you're way wrong.  At age 80, he finished his 21st  Ironman in Kona this year.  He says it's how he "tests" himself.  Hard to have higher personal standards than Lew, a role model to us all.  He also makes many older triathletes jealous as he's basically able to do this with only a modicum of injuries, often the rate limiting step to continued performance, particularly as we age.

Ever stood astride the commode after your long run, and instead of the usual concentrated deep yellow urine, you see blood?  Yep, it can be quite a shock.  But, like most things, if you take the time to do a little research you can narrow the list of possibilities...and cancel the call to the funeral home.

In medical jargon bloody urine is known as hematuria.  It can range from very slightly blood tinged all the way to frankly bloody.  It's not a diagnosis, it's a symptom.  But a symptom of what?  Let's follow a local Charlottesville runner, aged 22, runs 60 - 100 miles per week, is professionally coached and works in the local running shoe store.  He obviously has a handle on correct foot wear.  He started with a very slight pinkish tinge to his urine after his longest runs but over time has developed frank hematuria.

So, the first place we look is to a phenomenon called "Runner's Bladder" as it's both the most common as well as the most benign.  It's described  as bladder wall trauma, bruising, which leads to a small amount of blood in the urine.  When the runner decreases running volume or takes a couple of days off, it goes away.  For a while that is, until long runs resume.  It's said that running with a partially full bladder can eliminate this problem but it's a level of discomfort many can't stand.  Every heel strike reminds one of the urine's presence.

A visit to the Urologist by our runner reveals that although the mostly likely diagnosis is Runner's Bladder, the list of possibilities including kidney stones, tumor, infection, various kidney problems, etc., is pretty long.  So, to solidify the diagnosis, the Urologist plans to perform a cystoscopy - an in office procedure in which he will insert a small fiber optic scope through this runners penis up into the bladder. ("You're going to put a what into my where?"the runner was heard to exclaim!)  In the past, predominantly because of the larger size of the scope and the pain it would cause, this type of procedure was done in the Operating Room under anesthesia.

Good news.  During cystoscopy, our athlete's bladder wall revealed generous bruising and no other obvious source of bleeding.  So for now, he'll continue his running career, and his hematuria knowing that he's not causing irreversible long term damage.  Maybe he'll try again to learn to run with his bladder half full.  But he's 22 with a head full of steam.


Monday, December 13, 2010

Tachycardia, A Rapid Heart Rate

"She knew from the start, deep down in her heart that she and Tommy were worlds apart.  But her mother said never mind, your part is to be what you'll be."     Tommy, The Who

Heart beats. Too many of them.  This is a question I see on occasion.  Jill Athlete is serious about triathlon and uses a heart rate monitor.  She's used a resource like Joe Friel's, Triathlete's Training Bible to determine her training zones and even writes them on a piece of tape on her sleeve to make sure she doesn't get them confused when she works out.

Then, all of a sudden, one day on a routine run over familiar territory she sees a reading of 230!  What to do?

A)  Start self CPR
B)  Flag down a passing motor vehicle for a ride to the hospital
C) Panic, wonder about her will and if her "affairs are in order"
D) call 911
E) Rush home, post the symptoms on an Internet forum and wait for guidance from an anonymous source
F) stop, think reasonably and evaluate the situation

If Jill is symptomless, there's no rush to do anything.  If she's not dizzy, in pain, feeling weak - especially on only one side of the body, confused, etc., she has the ability to rationally evaluate what's going on and exercise common sense.

It's not uncommon that what may seem like bogus information is indeed bogus.  Was this erratic reading due to nearby electrical interference, overhead power lines, nearby welding, lead placement or slippage, etc?  It's unlikely that even if Jill were running with Matthew Mcconaughey, that she could generate a HR of 230!  Although many of us were taught the old 220 minus your age calculation, it would be pretty hard for one to get to the 220-230 range.

What quickly comes to the triathlete's mind is Greg Welch, winner of the 1994 Hawaii Ironman.  A few years after his victory over Dave Scott, Greg was forced to the side during the IMH swim course unable to continue.  He felt it was asthma, but was still able to get a 54 swim time.  (Pretty good, huh?)  What to do?  Stop and figure this out? Keep going?  He chose the latter and continued despite additional "attacks" during the bike segment.  He described these as feeling "...lightheaded, it's hard to see, I was short of breath, it's a horrible feeling."  Despite all this, and even more "attacks" on the run, he still finished in the top 15 with a 2:46 marathon.  What an athlete!

It took a pretty extensive work up that lasted quite some time until the diagnosis of ventricular tachycardia or V tach was made.  This rhythm is abnormal and can be very fast as well as irregular.  There are a variety of causes, some of which are managed surgically.  We don't think that our Jill, with no symptoms at all, has V tach.

Two other common arrhythmia's (abnormal heart beats) are atrial fibrillation and supra ventricular tachycardia. A different part of the heart is responsible for these two.  If they occur fairly frequently in a patient, they can be diagnosed with an office EKG at ones family physician.  Some require wearing an all day EKG known as a Holter monitor.  This records your heart beat during the day and when the abnormality occurs it can be interpreted.  Other arrhythmia's that produce symptoms even less frequently may require the triathlete to wear an event monitor to figure them out.  They wear EKG pads 24/7 for a month or two hooked up to a small monitor.  Yep, it's a pain.  But, like an enhanced TSA screen, it may yield valuable information.  When the user feels the symptoms, she triggers the monitor which records the heart tracing at that particular time.  This can then be used later to determine the abnormality.

So what advice do we give Jill?  I'd tell her to first look for some external cause for the errant number.  However, if it happens again, or she becomes symptomatic, she ought to give her family doc a call.

Greg Welch now "wears" an implanted defibrillator (sort of like the pacemakers you've seen implanted subcutaneously) which, if needed, can hopefully reverse a future episode of V tach...a potentially life saving maneuver.

Go Jill!



Monday, December 6, 2010

Raynauds Syndrome, Cold Hands and Feet in Winter Training

And I love to live so pleasantly,
Live this life of luxury,
Lazing on a summer afternoon.
In the summer time,....

                                                    The Kinks

Ah summertime, for many of us it's only a memory.  The arrival of winter has brought with it a host of training challenges. The cold, shorter days, more competition for pool access, the kids back in school, did I mention the cold?  And how we meet these challenges tells us a lot about our seriousness in the sport.  (In last weeks blog, Arthritis part 3, I talked about the committment and life changes made by Farrokh Bulsara who transformed himself into Freddie Mercury . " I guess the question is...are you willing to make the types of sacrifices Freddie made to achieve your goals?") 

The past few weeks have seen below freezing temperatures for those wishing to stay outside for the morning run/bike ride, particularly the long ride on the week end.  A simple solution would be to put your bike on a training stand and "ride" indoors watching CDs of last years TdF to see if Alberto wins again.  Funny, that same question is being asked elsewhere... the name clenbuterol ring any bells?  Also, I'm sure that a number of readers own Computrainers that can reproduce a variety of race courses.  I enjoy outdoor biking and if the road surface is safe, no snow or ice, I'll probably ride regardless of the temperature as will many of you.

But some have significant complaints about very cold fingers and toes despite several trials with gloves, mittens, chemical hand warmers or battery powered shoe inserts.  They report a variety of color changes in their digits when exposed to the cold. These occur secondary to spasms of the local finger arteries as seen below.

First, the fingers turns white and get a bit of a numb feel because of the lack of blood flow.  This loss of blood can make the fingers turn a purple blue color, almost black on some occasions.  When the spasms resolve the digits turn red for a short period and then slowly back to their normal color.  This is known as Raynaud's Disease or Raynaud's Phenomenon when it occurs without other disease processes.   Frequently, when it's a part of other diseases, it's called secondary RP.  A large study from Massachusettes found that 5% of men and 8% of women suffer from RP.

 The actual cause of RP is unknown.  What is known is that the blood vessels narrow because of spasming of tiny muscles in the walls of the arteries, eventually followed by sudden relaxation of these muscles opening the vessel back up.  The symptoms can be quite variable.  Some will complain of only a small amount of skin discoloration/numbness/tingling if they have mild disease.  Others get these same symptoms in their ears and nose.  An unlucky few will have such prolonged spasm that the tips of the fingers actually develop ulcers, get infected, and then become subject to amputations.  Fortunately it's a very small population.  RP can be exacerbated by certain drugs like beta-blockers or in occupations that have a great deal of vibration. Those who have secondary RP can also have a skin and joint disease called scleroderma or have it associated with with an arthritis-like disease such as Lupus or rheumatoid arthritis.

So, what's recommended for those who have this?  If possible, try to avoid the stresses that bring on the symptoms.  Try to keep your hands and feet warm, regardless of the outside conditions.  Companies like Assos carefully divide their catalogs by riding temperatures and recomend specific clothing, including gloves/mittens and foot wear for each temperature range.  If you smoke, this can exacerbate RP and it would be recommended that you try to quit. Diabetics need to take the best care of their disease possible.  They say that caffeine can bring this on. 

If the symptoms occur, warming the affected area is recommended.  Put your hands in your pockets, pants or arm pits.  If it's only a finger or two, put them in your mouth!  Some will even put their hands in warm water to more quickly reverse the symptoms.

A very small number of folks will need drug therapy or even surgery to keep the symptoms at bay.

So, if you can do your best to keep warm, those winter rides can be just as enjoyable as the summertime. Well, almost, till you get to the end at the local coffee shop.

Monday, November 29, 2010

Arthritis - Part Three

Supper time at the old triathletes home

 Making it to Kona    (written on the Big Island)

"And another one's gone, and another one's gone, and another one bites the dust, heh heh."  You know who sang these words.  But, earlier in his career, singer Farrokh Bulsara (you now know him as Freddie Mercury) was going nowhere in a band called Sour Milk Sea.  He took a look at his past, present and unpromising future, and made the changes he felt were required to reach the top.  I guess the question is...are you willing to make the sacrifices Freddie made to get here?  But first, answer these three questions:  1) Do I have  reasonable chance to qualify or do I just impress myself when I tell others "I'm training for Kona?"  2) Will my personal/professional life suffer too greatly if I take on this goal?  Does my spouse/significant other agree with this biased assessment?  3) Is it worth it in the end and what will have been the cost - how many irretrievable kids soccer games will I have missed?  (The 70.3 distance is to some the perfect race.  It takes a fair amount of training - but not your life - to finish respectably, you're not walking death the next day...or two. Also, it's easy to keep the family involved without dipping into the college savings account for airfare.)  Food for thought.

Parts one and two of this arthritis thread have covered the general pathophysiology of the degenerative process, anatomical findings and PAIN. When it comes to procedure specifics, arthroscopy was reviewed in the 8/25/2010 blog, microfracture originally done 3/7/2009, and bone/cartilage transplants (OATS) in that of 11/13/10.  I reviewed joint replacement in triathletes 7/7/2010 and the host of issues that diagnosis and operation bring forth.  

 I actually spent a good bit of time on the phone tonight with an experienced triathlon coach scheduled for knee replacement surgery in January.  This is a man who already knows the triathlon game and who's done a great deal of research on artificial joints.  The main point I tried to get across to him was that regardless of TV ads or the skill of his surgeon, he will not have the same knee when all is said and done.  He may get a terrific result, but he'll notice at least small differences in joint function.  His choices of athletic activity may have to take this joint into account on some level.  Good luck, Coach!

So, this leaves us with conservative care. You don't immediately (if ever) want an operation and would like to take steps to diminish or eliminate pain while maintaining function. There are many volumes devoted to care of the arthritic patient, even an entire medical subspecialty - Rheumatology - so I'll just touch on a few things. As with most medical issues, an accurate diagnosis is an essential starting point. Does your arthritis affect only the joints or perhaps other body parts? An educated patient has the best chance to retard progression of the disease while maintaining the highest quality of life. Learn what you can about the problem and be your own best advocate. Some would say this could be true of any illness or injury and I'd tend to agree.

This may be accomplished through a host of options including weight loss, life style modification, changes in activity choices, joint protection, medications or injections, etc. Trying to balance the seemingly opposite goals of doing well in one's age group in a race as opposed to getting a damaged joint to last as far into the future as possible can be a challenge. In short, just like the triathlon coach facing knee replacement, do your research, ask your physician the right questions, and take charge of your own body. You are a triathlete after all!



Saturday, November 20, 2010

Knee Arthritis Part Two -Pain!

Bob Scott

" 'Bill I believe this is killing me!' as the smile ran away from his face."    Billy Joel

This is the second in a series of three pieces on arthritis.  We hear so much about "degenerative change" but it's causes are not always well understood. Those who have it know one thing - it hurts!

Although there are approximately 100 different varieties of arthritis, many accompanying other disease processes you've heard of like Lupus or Lymes Disease, Osteoarthritis is by far the most common. We think of  it as an old persons problem (old being a relative term in triathlon - just ask Bob Scott (above), Kona course record holder with a 12:59 when he was 70!)

Certainly arthritis is more common in the over 65 crowd but it's prevalence begins to increase by age 50 in men and, unfortunately, age 40 in women.  It's frequently a progressive problem which ends up with joint pain, swelling and stiffness, and can limit one's quality of life.  Three fourths of adults over 70 will demonstrate some degree of arthritis on plain x-ray.  Over time, the joint lining cartilage is eroded down to bone leading to pain, disability and narrowing of the joint to the point where it could become "bone on bone."

The drawing below shows the basic anatomy of a right knee, particularly the femur, the upper bone.  The cartilage lines the end of the bone and is normal, smooth and intact on the left side.  But, just to the right in the area labeled arthritis, you see that there are stellate cracks, with wear down to expose the underlying bone This might be the location of an injury in the past. Or, perhaps the athlete had a meniscus injury/removal earlier in life.  It's a lot more common than you might think. 

This photograph is what an arthritic femur would resemble at arthroscopy. Rather than being lovely and smooth, it looks more like an old tennis ball!

The function of the joint worsens over time as the disease process progresses.  Knee pain and swelling, initially present only with activity, become an issue at rest.  Many will lose range of motion and find their lives restricted by the joints lack of mobility.  I've had patients over the years report being "held hostage by the pain" or "a prisoner of my knee." 

If left unchecked, the joint ultimately wears out completely as shown on the x-ray below.  The black space between the bones on the left represents the normal cartilage space, but on the right, the bones are touching. This represents end stage disease.  One of the options for this patient, if symptomatic enough and a failure to conservative care, would be replacement.  As you'd imagine, triathlon probably isn't on the list of recommended activities following an operation of that magnitude.
  Next week, part three, options.


Saturday, November 13, 2010

Knee Arthritis, Continued - Aging (Over 30) Triathletes Take Note

Sister Madonna Buder sets the example for us all

"You're not shy, you get around, you wanna fly, don't want your feet on the ground. You stay up, you won't come down..." Foreigner

Of the over 100 blogs that I've done, the one that has generated the most interest was about arthritis of the knee and a procedure known as microfracture, 3/7/2009. This is an arthroscopic operation where an attempt is made to allow the damaged cartilage to heal itself. It's usually pretty successful but the results may not last forever. In cases where microfracture is considered inappropriate, Orthopedic Surgeons have other arthroscopic tricks that can hopefully extend the life of the knee. One of these involves transplantation of bone and cartilage plugs from one part of the knee to another.

But first, a little of the basics. The femur is the upper of the two bones that make up the knee joint. The bony surfaces are covered with articular cartilage (that white-pearly grey stuff at the ends of turkey bones) to make joint contact smooth and frictionless...until there's an injury or just wear and tear. This wear and tear would also be known as arthritis, or osteoarthritis. It's the deterioration of this supportive cartilage, pretty important stuff, which, although it's pretty hard, is slick enough to allow the bones to glide, one on top of the other. 

Cartilage is also a pretty good shock absorber.  If the cartilage wears to the bone, so called end stage arthritis is present and usually accompanied by significant pain. You might ultimately find yourself headed down "Joint Replacement Lane".

                                                                             So who's at risk for arthritis? The obese, females more than males, those with a positive family history of arthritis, smokers, and people who've had some type of injury to the joint just to name a few.

Surgeons have been doing bone and cartilage transplants for over 100 years divided into two groups: taking the tissue from a donor (allograft), usually deceased, or using the patients own tissue (autograft). I'll only discuss autografts today.

As seen in the picture above, plugs of cartilage covered bone are harvested from an out of the way area of the knee, and then placed mosaic-style in the prepared area of arthritis.  Great care is taken by the surgeon to get the size and location of each plug correct as it can spell success or failure of the operation. Following the case, weight bearing on crutches is the norm until it's felt that healing has taken place.  This technique is offered by many Orthopedic Surgeons.  If it were something you were considering, just make sure your doc does a lot of these as, take it from the voice of experience, it can be pretty easy to screw up until you learn it cold.

Friday, November 5, 2010

"I Felt So Good, Like Anything Was Possible"

Tom Petty and the Heartbreakers, Runnin' Down a Dream

The finish line in Kona about 12 hours after race start.

"ANYTHING IS POSSIBLE" This is one of the catch phrases of Ironman, one you hear frequently in Hawaii. You both hear it as well as see it. Some even live it.

There are so many heart warming stories that come out of this race each year. A good number of the first timers do not meet their expectations and on the morning after the race, honest evaluations of the heat and conditions seep into the conversations for the first time. "Mother Nature always bats last," or some such phrase might be overheard. In spite of this, the athletes share this common bond with the island as they lean back, close their eyes and recall particular portions of their day...both bad and good. And then they smile. That wry smile that comes only with experience.

The above photo is from ALII DRIVE, the finish line, where so many stories evolve. You hear them on race night, "I was just cruising down Alii Drive, man!," or at the Finishers Banquet, "The huge party at midnight at the finish line on Alii Drive was just awesome." Alii Drive, milepost zero, where it all starts and finishes.

By any other name it will always be Alii to the finishers:

NOVEMBER - Dreaming and planning time. (Part one)

You know how on January 2nd, when you can't get a locker at the health club or gym, and you're used to having light conversations with the regulars, but now there a lots of new folks and the air is almost festive with excitement? Unfortunately, you know from experience that in 60 days it'll be back to the same old crowd.

Triathletes are the same...dreamers all, and at this time of year, they're reviewing recent races, successes and failures, saying, "If I can train just a little harder next year I can take the age group...or get that slot..." Maybe what they need is to train smarter not harder, to reduce garbage work outs, to reduce injuries, or at least be able to train through them. Listen to the words of folks like Ben Greenfield who did an excellent USAT webinar 11/4 on how to minimize your down time getting a hold on injuries and returning to plan as quickly as is safe. In other words, create your plan mostly with your head and not your heart. Come race season, maybe if you're lucky, anything will be possible.

Next week, back to business as the triathletes injury resource. Happy training everyone.


Friday, October 29, 2010

Yes, Alcohol Can Affect Your Performance


So how does alcohol affect endurance athletes anyway?

Beer. It's not just for breakfast anymore.

When you're at a wine tasting with a bunch of doctors it can be kind of boring. One thing for certain is going to come up - a study done a number of years ago showing a protective effect of alcohol consumption, but only with one or two servings per day. More than once you'll hear someone state, over their third or fourth glass of wine, "I'm really working on that protective effect." It's like they want you to think they'll live to be 140 years old!

This observation is true but, again, it's optimal effect is with a single drink, possibly two, daily. The other side of this equation is a college student, one of my kids roommates for example, a gent we'll call Joe. Joe didn't show up back at the dorm one Saturday night his freshman year, and when he stumbled in mid day on Sunday - with a big plaster splint on his hand from an injury of unknown origin (which would eventually require surgery) - and, oh yeah, the papers releasing him from jail where he'd spent the night having been arrested for being drunk and disorderly, he just sighed. But, at some schools, isn't that the norm on a college Saturday night, how much worse does your behavior need to be to raise the ire of the gendarmes?

I make this example to provide a range of minimal to near maximal consumption and the potential effects on athletic performance. Many of us, particularly the more youthful, may underestimate the ability of alcohol to reverse the effects of those hours, even weeks of training. It can reduce your endurance as well as your decision making capacity as illustrated above. It effects your pattern of sleep in both duration and cycle, particularly REM sleep, essential to memory and hormonal development. This has been shown to have a deleterious relationship with post workout muscle repair, the key to the training effect. ( See Triathlete's Training Bible by Joe Friel) The hormone HGH, human growth hormone, is one that's gotten a good deal of press recently. Part of it's function involves muscle repair and growth, and alcohol has been shown to decrease HGH secretion by 50% or more! This is an important sentence that should be read twice.

Most of already are aware of the diuretic nature of alcohol which contributes to dehydration. And, in a sport where we spend so much time and effort figuring out our proper diet, race nutrition and race hydration, alcohol only compounds the problem.

There are a number of other issues with alcohol including inhibition of nutrient absorption like zinc, vitamin B12 and thiamine just to name a few. Remember when we used to drown in Tour de France information when Lance was pushing for number 6 or 7. Heck, they'd even show footage of the team dinners after he won a stage, no alcohol in sight of course. I recall seeing Jan Ullrich with a wine glass in his hand at a Team Telecom meal. Retrospectively, maybe Lance knew something Jan didn't. Maybe he knew a lot of things Jan didn't!

So, for your best athletic performance, keep the alcohol to a minimum, Doctors orders.

Friday, October 22, 2010

A Gentlemanly Ironman Head Referee

"Powdermilk biscuits give a shy person the strength to do what needs to be done." Garrison Keillor

Several years ago, while on a rolling section of the Queen Ka'ahumanu Highway portion of the IMH bike course, one of the motor scooter bound bike refs was just itchin' to get someone. They sat off to my left rear. Lurking. Waiting. Like a mosquito on a hot summer day. There was a sizable group of athletes whose positions relative to the other bikes were totally dictated by the terrain. A spreading out occurred going downhill with the inevitable bunching up come the next short up hill. And that's when the ref struck nabbing a slew of folks allowing them a short "unplanned rest" in the penalty tent. I sent a note to the race office describing what I felt was just
not the standard I'd expect of a referee, unfair really, and the following year I saw no ref behavior of this kind.

Fast forward to 2010 when I meet the Ironman Head Referee, Jimmy Riccitello, the man does indeed set the standard. Multiple times I saw him help out an athlete or aid in race conduct at this years event, never drawing attention to himself. On the Friday afternoon before the race, during bike check in, one woman's race wheels didn't make it to Kona and here's Jimmy, butt on the pier, stretching out some sew ups, which he helped this woman mount. All real casual like this happens every day. (Maybe it does.)

12 hours later, the transition area is a madhouse with 1900 athletes, volunteers providing assistance, and bike repair teams making last minute fixes. And where's Jimmy? Helping an age group woman trying to figure out if her speed suit was legal for the swim. Sure you could say why would someone wait until an hour before arguably the most important race of her life to figure this out. But he didn't. He researched the
question and determined that a short run of this particular suit was not legal, unfortunate for her in that hers was one of them, but she was able to follow the letter of the law with a clear conscience.

I have three kids, and, at the heat of action during the race asked Jimmy how many he had. "Two," was the answer. I told him I hope they married my kids if they were anything like their dad. He just smiled. Later, when recounting this interaction to an IM employee, she added, "I feel honored to have gotten to know him and work with him the last several years. I have also been with him and his children outside of our work worlds and can validate that he is a wonderful father…a better parent than many. He’s not just the 'good time dad', he truly is a wonderful, caring parent and his children are a reflection of him."

There are other examples but these three illustrate the point. In 2010, where the national pastime is complaining, we are so fortunate to have this gentleman help us both follow the rules and have a successful day doing so. Maybe he thinks of the athletes as his 1900 children. Who knows. Thanks, Jimmy. Thanks, Dad.

Saturday, October 16, 2010

Road Rash, Torn Up Skin, What To Do

"Ain't no doubt about it we were doubly blessed, 'cause we were barely 17 and barely dressed." Meat Loaf, Bat out of Hell

Possibly without intending, Meat Loaf was describing the amount of protection one gets from cycling clothing when you hit the asphalt. Barely dressed. But, you look good doing it. Right?

What would you think if this were your elbow? You crashed hard, went to the local urgent care and got sewn up...but things went down hill quickly when you started to develop a fever. Then, rather than having less pain as time passed it only increased. And then you started to sweat. Heck, you're a veteran. You served 5 years as an instructor at the Naval Nuclear Power School, you can handle this. Why, it's just a cut, right?

You visit your friendly local Orthopedic Surgeon who cultures the wound (put in a cotton tip, send it to the lab to see what unexpected bacteria can be found in what should be a sterile environment). Then you're told that your next stop is the operating room...NO, you cannot go home to let the cat out or turn off the sprinkler because you're being prepped for immediate I&D, irrigation and debridement. You meet the holding area team, the anesthesiologist, the circulating nurse for the OR as she seats you in the center of the operating table, etc. You're surprised how cold the operating table is against your unclothed butt! Just the first of many unfamiliar sensations.

This is all a true story. A triathlete suffered a fairly involved injury, without broken bones, to her arm above the elbow and the above sequence occurred. This picture is her arm about a week ago. She's also under the care of an Infectious Disease specialist to help manage the antibiotics as appropriate to the organisms cultured at surgery. So what are the lessons that we take away from this? Well, it's hard for many of us to get thru a full season without dumping our bikes at least once - or more. If we're lucky it's just a skinned knee or lateral ankle that with a minimum of local care heals uneventfully assuming an intact immune system. What about that dog bite? Or that more significant skin embarrassment with depth and significant bleeding?

I'd suggest beginning by lavage of the area as best you can with the contents of your water bottle(s). I know a number of athletes who drink very little from them, particularly in cooler weather, and carry them for just such an emergency. You're prepared for a flat, loose spoke, broken chain, etc., why not be prepared for this is their motto. While you probably wouldn't use water from the creek, tap water from the nearest source to irrigate out any debris while still fresh helps a great deal. If there's any doubt, seek medical care. If the wound is over a joint and sizable, if it's at all deep, if you see a tendon, bone or joint, these are all reasons to proceed to the local Urgent Care right away. The longer you wait, the more time any foreign matter has to set up shop. You can also update your tetanus at that time. In fact, I know one athlete who called his docs office within minutes of an unprovoked dog bite, was told to "come now", which he did, and had the wound cleaned, tetanus administered, etc. in about an hour allowing him to finish his ride. Can't leave that calendar space white, even for a trip to the doctor, now can we? (See "Once a Runner")

How can you possibly not PR with this on your head?

Tuesday, October 12, 2010

Two Ironman Stories, 10/9/2010 Kailua-Kona, Hawaii

Sometimes, in surprising ways, the human spirit of kindness saves the day. A triathlete I know, despite his best efforts, is tad forgetful at times. I worked the men’s changing tent in Hawaii last year when this gent came in flying after a pretty good swim. As is custom, he dumped his bike transition bag on the floor, quickly changed in to his biking gear, and was out the door. In a matter of seconds he was back having forgotten an item. He eyed me, and asked if I could find his bag and retrieve it. Well, if you’ve ever served in this position, you know that there are 50 men at any one time in the tent, all moving as quickly as they can in many different directions, and the stress level is right high. In short, it’s controlled mayhem with a great deal of activity in a very small space. Also, when an athlete is dressed and out the door the bags are thrown into one huge pile to be sorted later.
But, he hadn’t been gone long so I gave locating it a try. After searching through about 50 bags, we realized the futility of our efforts and he abandoned the search sprinting toward his bike (which went fine by the way.)
Fast forward to 2010, same situation – different volunteer – and our buddy is out the door…and back in a flash having forgotten his sunglasses. These are pretty important given the wind and heat of the Queen Ka’ahumanu Highway and the near complete absence of shade. Again the volunteer made a noble, but unsuccessful search for the bag containing the sunglasses. Without hesitating he said, ,“Here, take mine!” At first this gent protested, but after a second offer , an order actually of, “Take mine”, the athlete did and had a quite successful ride. At T2, he looked for that volunteer but there’d been a shift change. The sunglasses were left with thanks and instructions for return to the volunteer.
This helping gesture, non-competitor supporting competitor was done in the truest spirit of triathlon. I think that both of these folks benefited from this spontaneous and selfless act.

One of my roles on Saturday was being stationed at the entrance to the men’s changing tent. At the debriefing last year, it was noted by many that the pros exit the swim like a house on fire and when they tried to change direction to enter the tent, they lost footing ending up on the ground. My goal was to eliminate this for 2010. It worked. By simply getting eye contact with the athlete and actively directing him to turn, nobody “went to ground.” In fact it worked so well I was encouraged to keep my position and direct the age groupers, women to the women’s tent, men to the mens. And, it was almost completely successful. Almost! When you consider 1800 swimmers passing by you in a six foot wide space they almost suck you along. I was able to prevent 9 women from mistakenly entering with the men…but not the tenth. This somewhat smaller woman was directly behind a large body athlete and it was only out of the corner of my eye that I saw her slip in. But, because of the sheer numbers of bodies, I was blocked for a moment from following her into the tent. By the time I was able to thread my way in, she was already dumping her bag and ripping off her swim suit – almost. Interestingly, she was so focused on the job at hand, she didn’t notice that she was the only woman in a tent with forty men in various stages of undress! In one quick movement I got her arm and her bag. Exit stage left and back to my post. One can only imagine the reaction in the tent if I'd missed. As they say on TV, priceless!

Tuesday, October 5, 2010

Advance Race Prep and Bruce Dern

"From here on in, I really gets grim. For 99% of the people still left at this point, they are possessed with one thing, finishing. They’re saying to themselves one thing, “If I can just be standing at the finish, I've won,” and they’re right.

But, for the gifted few, for our 1% who are still competing, that are still racing, they’re more than standing. They’re wondering, can I catch that guy up there? And what about the guys behind me, are they coming up on me, are they picking up on me, can I get him? Because let me tell you something. This is it. The last hour of this triathlon, on the pavement, at 110 degrees, that’s when we’re going to find out who the hell the Ironman really is!”

Bruce Dern, Freewheeling Films, 1982

Yep, it’s race week in Kona. But it’s early and people are still light, joking, horsing around on training runs down Alii Drive or at the pier. The attitude is almost festive at Lava Java or the King Kamehameha hotel. But it’s only Monday and the nerves won’t start to fray till later in the week.

I don’t think it matters at what level you race. Everybody goes through this cycle...so why not get “race ready” early? Why not prepare for a race, particularly one at a distance from your home (using your written check list of course), a week or two in advance. Then, the night or two before, when looking at the pile of race gear you've created, only a couple things are needed to complete it. It also depends how important the race is to you. For Hawaii as an example, many have been known to change tires and tubes two weeks in advance, regardless of their age, to have the greatest safety margin and lowest potential for flats.

It's always befuddled me how folks can arrive at the race with almost no time to get inspected, body marked, etc. How can they possibly do their best with so little preparation. Maybe it's not important for them to do well...then why race?

Once you develop a race day routine that you're comfortable with, when the guns sounds you'll not only be fit but relaxed and ready for a fine day. As elder statesman Bill Bell said in last weeks blog, you'll be ready to "Enjoy your day."

Sunday, September 26, 2010

Ironman Race Day in Kona - Best Advice

..............................Bill Bell

"Just once in his life, a man has his time. And my time is now, I'm coming alive!" St. Elmo's Fire

Race Day is October 9, 2010. Batter up!

The above photo of Bill Bell reminds us to learn from those who've walked this path before us. A number of years ago at the Thursday evening carbo dinner, they had on stage the oldest man and woman standing with the youngest man and woman in that years race. MC Mike Reilly asked the two elders if they had any words of wisdom for their two young counterparts in the event 36 hours hence. Never bashful, or at a loss for words, Bell strode to the microphone and uttered words I've never forgotten. "Enjoy your day. You may never come back here or do this race again so I feel strongly that you should just enjoy your day." He was right of course. Don't forget.

In last weeks blog, I tried to sum up many years of mistakes so the first timer and support team - family and friends - could have the best Hawaiian experience possible.

This week I'll focus on race day. Actually, this will begin at noon on Friday. You've packed your blue bike bag and red run bag without distraction. You've had your bike inspected at the base of the pier and racked with a volunteer. Now you hang your two bags - remember, no bag access race morning. Although the volunteer's job is to gently guide you back off the pier, this is the perfect time to see the steps being built into Kailua Bay that you'll use in the morning. Why not pretend you've just exited the water and simulate the swim-to-bike transition by following the same steps you'll do in the morning? Shower hoses, changing tent -No, not that one, it's the ladies changing tent. You'd get on NBC for sure...but in a pretty negative light. Understand the path you'll take out of the water and then again when getting off the bike at the start of T2. Understand it cold.

You already have a pre-race plan including supper, sleep, what to eat and drink race morning before you get in the water. And, you've planned for months what you'll eat and drink during the event. So, the important thing here is to get started earlier than you think. There's always a line at the port-a-potties, you may have an early morning bike need, back ups have occurred at body marking and the like. Get there early. Get everything done and then relax. Again, get in the water early thinking lines may form there as well and you can stand in knee deep water as easily as on the pier.

When the gun sounds, you're relaxed, you're experienced, you're ready. Ready for a challenging day, but a great day none the less. You will remember this day for the rest of your life. Really, you will.

Bill Bell photo WTC

Sunday, September 19, 2010

It's World Championship Time in Hawaii

"It's going to be a hard day's night. The Beatles

We're 20 days till the cannon blast signals the start of the 2010 Ford Ironman Triathlon World Championship. The athletes who are racing this year are beginning to struggle with the need to taper opposing that intense internal drive to get every bit of training they can out of every day. It can be as much as 20, 25, even 30 hours per week. Age groupers too! For the first timers there are so many questions involving bike transportation, accommodations, training on the island, heat acclimation, and learning as absolutely much as possible about the race and conditions to ensure they're in the annually expected 93% who finish the event instead of those who don't.

I think the biggest mistake that newcomers make is that in spite of spending 7, 8, 10 or more days on the Big Island, they don't get it. They are so focused on the event that although come race cut off time at midnight on Saturday it's "mission accomplished," they've totally missed the Hawaiian feeling of Ohana (family) or the spirit of Aloha. And, for those who've brought family and friends, they've learned little to nothing about this wonderful place as they become consumed with Ironman.

To be fair, it's this goal oriented behavior that got them here, but with actual pre-race training at a minimum now, there are frequent opportunities to learn and entertain while in Kona. Having been there 20 times, here are ten suggestions to ensure both the best race and the best experience for racer and family alike:

1. Get your bike needs taken care of early. Have it re-inspected after you assemble it by Bikeworks just because this costs less than a malfunction on race day. Drive to Hawi. Learn the route by heart and ride up Kuakini Highway a couple times - just because.

2. Early in the week, take a snorkel boat cruise on board the Fair Wind out of Keauhou (7 miles from the pier). Although spending time at the pier and Lava Java talking Ironman is beneficial, it has an end point. You won't get shot if you leave downtown for a little while to snorkel.

3. Eat at some place different every day. Basil's, Splashers, Kona Inn, Hard Rock, Lulu's, they all have something good to offer.

4. Swim a little many mornings -at 7am so you can the light and shadows - more days than you think you need to. But not a lot. It's fun, it's social, and where else can you swim out to a coffee bar?

5. When thinking about gifts for those back home, particularly kids, both Longs Drugs and the ABC stores have a wide variety for not a lot of money. You will spend more money in the Ironman store than you think. ("Well, I'll never be back here again and I do need 10 more triathlon oriented shirts in the dresser."

6. Run the underpants run on Thursday...and bring a camera. It's less than 2K at about a 10min/mile pace...when you can stop laughing. Bring a special hat or mask. One guy was Elvis a couple years ago and it worked. Have your family also run the PATH safety 5K on 10/3 downtown. It's fun and for a worthy cause.

7. Everyone who comes with you should, no MUST, be a race volunteer - sign up before you go. Do it today. I don't think I've ever heard anyone say it wasn't the highlight of their time on the Big Island.

8. On Saturday, say THANK YOU to every race volunteer you encounter.

9. Be kind and patient to the people of Kona - this is their home we're invading.

10. Say hello to some one you don't know every day. And, if they're having a little trouble since English isn't their first language, take a breath and see if you can work it out. It just takes a little patience to be a good ambassador. And besides, it's fun.

11. I said there'd be 10,but I forgot one. After you finish, and get your medal and something to eat, and you realize you're not going to die...when they take you to the massage tent and ask if they can help you, don't say no. Get a 5 minute foot massage. It's to die for. And besides, you earned it.

Friday, September 10, 2010

Frozen Shoulder

"Outside of a dog, a book is man's best friend. Inside a dog, it's too dark to read." Groucho Marx

While donning my running shoes by my Jeeps interior lighting one recent morning I realized we only have 12 hours of daylight this time of year and it's decreasing steadily. Since work takes up 8 of them, some of our training
must be done in the dark. I have a friend who used start his training
day at 0230! Yes, he's a mite intense. He'd get a majority of his training done in the dark.

You need to go the extra mile to absolutely ensure your safety-especially from motor vehicles. While running, attention to a possibly slippery road surface, choice of routes, bright clothing, reflector vests, even a red strobe light on your butt while always paying attention to your surroundings.

When cycling, riding single file is even more important than in summer daylight. Although we've all seen riders with hardly a reflector, I ride with 3 red lights behind: 2 solid on my belt and a strobe under my saddle. My friend has a suit with lights up and down the arms resembling Landing Signal Officer on an aircraft carrier. But, by gosh he's visible. Careful, it's a jungle out there.

Frozen Shoulder
In the office this is known as Adhesive Capsulitis. The patient is usually not aware of trauma (although a percentage of this group has has recent trauma or surgery to this shoulder) but notices an ever increasing loss of motion, a "capsulitis" or shrinking/tightening of the capsule around the shoulder joint. For some reason, it's much more common in women than men, non-dominant shoulder, aged 35-55. Diabetes seems to increase the risk of developing FS. This is not arthritis or infection although its true cause is not known.

Conveniently, the natural history of the disease can be divided in the freezing phase commonly lasting 4-6 months, the frozen phase lasting 4-6 months and finally the thawing phase lasting the same. The initial phase is characterized by gradual loss of motion (can't put hand overhead, fasten bra behind back, get wallet out of pocket and so forth) and pain. Once the "freezing" has slowed, there's also less pain. During the following "frozen period, motion is limited but so is pain. Subsequently, when the process begins to retreat, the pain recurs to a degree.

Treatment is mostly supportive with a small role for Physical Therapy, pain control, and a program to try to maintain motion. Patience is a must. A percentage of these folks don't have a return of motion and may be a candidate for what's known as a manipulation under anesthesia or an arthroscopy to release adhesions inside the joint.

Overall, this is usually a self limited process, hopefully more of an inconvenience than a disability.

Thursday, September 2, 2010

Should Triathletes Donate Blood?

"Back off man, I'm a scientist." Peter Venkman, Ghostbusters

I think triathletes should donate blood. All of us. Doesn't matter if it's the Red Cross or your local blood service, just do it. Did you know that only 3% of the population gives blood so that 100% may ultimately benefit?
The first thing, as an athlete, you want to know how long it takes to return to the predonation levels. Back to where you're not actually reverse blood doping. Well the plasma level is back up in 24 hours and the oxygen carrying red cells normalize in about 4-6 weeks. That's why you can donate again in 8 weeks. Think about how frequently you read on Slowtwitch about someone being injured, car hits bike and the like, and then think what if that becomes you? Will there be blood available? The red cells only have a shelf life of 5 or 6 weeks, some of the components even less.

So what happens when the other 97% of us go to the blood bank to donate for the very first time? First you register where they ask a bunch of questions, all very confidentially, to make sure it's right for them and right for you. They even take your pulse, temperature and blood pressure free for nothing. Consider that the swim, and T1 is getting your arm really clean and inserting a sterile, brand new needle for the blood draw. The bike, actually have the collection bag fill takes only a few minutes - faster than some of us do a transition in an iron distance race! Honestly.

T2 is where they finish up and wrap your arm with a colorful (quite noticeable to all colorful - "Why yes I did just give blood, thanks for asking," and thinking me a real stud!) The run is to the snack area where you can have unlimited Oreos, Fig Newtons (an IM sponsor) sodas, etc. and in 10 minutes you're back on the sidewalk ready for action. A PR for sure.

Imagine how good you feel when you do something for others. And it's September so many of us have nearly finished our racing season making it an ideal time to give. And for those of you who say, "But I'm afraid of needles," this is totally out weighed by the "accomplishment they get at the end of the successful donation." Did I mention the Oreos?

So, get out the phone book and find the nearest place to give. You'll be so glad you did. It's a pretty cool thing to be proud of. At least I think so.

Monday, August 30, 2010

Workout Guilt, Of Course You Have It

"It's not having what you want, it's wanting what you've got"Sheryl Crow

Triathlon training takes a long time. (Duh, many of you say.) This is especially true when preparing for the longer distance events. There's only so much you can do squeezing training in and around your schedule before you have to do the same to their schedule whether "they" is wife, husband, kids, co-workers, etc. Frequently we find ourselves battling that inner demon who tells us that we need 30 more minutes on this run but our soul tells us to go home and relieve the baby sitter.

I was rereading John L. Parker, Jr.'s "Once a Runner" this week and thought a page spoke directly to this. I'm sure you've all read this wonderful text - if not go to Amazon.com and order a copy right now - but wanted to refresh your thought processes reminding us that endurance athletes have had to vault this hurdle for ages.

Here are fictional runner Quenton Cassidy's thoughts on the subject while tubing down the Ichetucknee River with his girlfriend Andrea:

"In order to arrange this day of perfect drifting, an entirely traditional local pastime, he and Mizner - now floating up ahead with his date - had arisen at 7:30 and run seventeen miles. It was the only way they could spend their day in the sweet haze of Boone's Farm apple wine and still appease the great white Calendar God whose slighted or empty squares would surely turn up someday to torment the quilt-ridden runner. They went through such contortions occasionally to prove to themselves that their lives didn't have to be so abnormal, but the process usually just ended up accentuating the fact. There were several ways it could be done. If they were going to the beach, they might put it off and run when they got there, but contrary to popular opinion, beach running is only jolly fun for the first five miles or so. After that, the cute little waves become redundant, the sand reflects the sun up into the eyes blindingly, grains of sand slip annoyingly into the heel of the shoe or flip up on the back of the leg. Fifteen hot miles on a long, flat beach sounds like good sport only to those who haven't actually done it. Also, the ocean is too infinite: the run seems as if it will never end.

They could always put off training until they got back in the evening, but that just made things worse. No beer! None of the sticky wine! Their friends would slyly tempt them, to see if they really took all that training stuff seriously. It was too much to ask. Better to get it all over with and then be able to enjoy the day like any other citizen."

Any of this sound familiar in your life. I'm bettin' the answer's yes.

Wednesday, August 25, 2010

Arthroscopy For Arthritis, When Is It Appropriate?

"I'll take any risk to turn back the hands of time." Styx

Triathlon covers all walks of life and all age groups. It's addictive, and it's cumulative training, plus getting older, can have deleterious effects on the body. Why do we see fewer and fewer folks in the older age groups? It's not 'cause they're busy playing Mahjong at the Senior Center. As we begin to "wear out" arthritis can become part of the picture and we reach for the cure so we can continue training and racing.

When the knees start to go (and we're not talking about the patient with some type of inflammatory arthritis here), many remedies can be recommended and be helpful including rest, or decreased training load anyway. Some variety of braces or sleeves are often of benefit. Therapy of one form or another with oral meds and injections have been known to be helpful in specific cases. And what about surgery?

We have become so accustomed to it that more than once I've had a patient refer to arthroscopy of the knee as "band-aid surgery." Honestly. They have no more respect for undergoing and anesthetic and surgical procedure with all of the attendant potential risks and complications than that. Please, only consider surgery when non-surgical means have been exhausted and the benefits outweigh the risks for you.

So which patients with a deteriorating knee can a scope help? Primarily those with some type of mechanical symptom, catching, snapping, locking, that sort of thing. Being under 50 helps as does normal alignment, not smoking, not being over weight, shorter duration of symptoms, and hopefully minimal changes on x-ray. These are standing, weight bearing x-rays taken of both knees to compare the painful and non-painful knees. We're not talking about an MRI here.

I taught a course to about 200 Primary Care physicians last month in SC and one of the take home points I tried to leave them with was that "The single most common x-ray taken in my office is the weight bearing view of the knees." We also talked about the fact that the patient needs to go into this type of procedure with open eyes and realistic expectations. Following arthroscopy, many surgeons give their patients the intra-operative photographs of the knee so they can have a visual reference to understand what they're dealing with and what the future holds for them.

So, if you are considering a scope to "clean out the knee/knees at the end of the season to get ready for 2011," make sure you've had the correct x-rays and have gone through the options carefully with your surgeon. Good luck.