RESOURCES

self-help medical advice sheet

Hi all from your race doctor, Lynne John. With just over one month to go until the race, it’s timely to give you some pearls of wisdom re looking after yourself before and during the race. With any luck that’ll mean you don’t get to see me, nor any of the other medical team for the whole race and I get to camp out in glorious wilderness and have more sleep than you do!

Last year we had numerous injuries which broadly grouped as follows:

1. Feet – a huge problem for man, from minor blisters and toenails ‘floating off’ painfully, to complete (WW1 era) trench feet, where skin was peeling off in strips
2. Sprains of joints/wrists/ankles – and muscle strains (ITB/forearm/lower shin & ankle)
3. Impacts-broken bones/concussion
4. Dehydration
5. Wasp stings
6. Skin tears – shins/forearms/bike gravel rash, followed rapidly by infections (due to your immune system being suppressed by high activity/fatigue/dehydration)
7. Chaffing of feet/trunk/butts/’undercarriages’/mouths
8. Problems due to overuse of self-medication – stomach (ulceration) AND kidney damage from (NSAID) anti-inflammatory pain-relievers +plus some possibly some hallucinatory effects of other pain drugs (codeine/tramadol) under the duress of the race
9. Eye injuries from minor scratches to the eyeball to a perforation from gorse bush-bashing which necessitated the athlete withdrawing for sight-saving treatment!
10. Sleep monsters

Prevention is better than cure

In nearly all cases, prevention is a lot better than the cure. So here’s how to make your race more enjoyable and effective:

1. Feet – due to the prevalence of foot problems even in the ‘top’ teams, I have formulated a special sheet called Footcare Advice which is available under the Resources tab. Your feet will, most likely, be constantly wet – due to immersion and your own sweat. Key points to consider; don good sturdy worn-in shoes, dry-dry-dry ( even just let steam off) at every minor stop, apply chaffing goo, cover rubbing points early with tape, AND IMPORTANTLY CONDITION YOUR FEET – get out for multiple 6-8+ hour rugged tramps now. Merely running on roads won’t work for you
2. Sprains/strains – training helps! Building up to long hours on your legs or paddling is key. Start low/go slow. If you need to strap, apply a protective stretchy mesh (mefix/flixomull etc) to your bare skin before the sports tape or you will lose strips of skin during the required changes. Consider visiting your favourite physio to be shown how to apply strapping. Last year many athletes developed leg swelling due to racing and the applied strapping became tight and constricting, cutting off circulation and stripping skin. You may need to reapply daily
3. Consider use of light protective helmets on high mountainous rocky  stages
4. Drink lots, mainly according to thirst, while exercising/sweating – up to 0.75 litres water/electrolytes hourly for half of the 24 hrs in the hot parts of the day. Aim to be ‘peeing clear’ frequently. This way you will perform optimally; clearer thinking, stomach/skin infection/kidneys will be protected
5. Wasps/sandflies – take an antihistamine immediately after bites to avoid swelling and infection
6. Shin high gaiters and long light (polypro?) sleeves if possible. Those tiny scratches soon fester in race conditions, as the ‘normal skin bugs’ have a field day on your moist, sweaty immunosuppressed body. Wash off mud/grit in streams or under taps asap + daub with iodine daily to zap the bacteria (good for feet too). Cover grazes directly with the sticky mesh above or a massive bandaid! Covered (cleaned) wounds heal quicker. Remember to apply sunblock often to avoid suffering
7. Chaffs – invest in a big pot of antichaf/Gurney Goo and apply EVERYWHERE  at every transition (and more often). Feet/toes/armpits/nipples/butt creases and orifices. Re bottoms – the race stress + concentrated electrolyte mixtures you quaff often produce race diarrhoea and even ‘piles’. You may need a few stopper tablets to take ‘just in case’. The mouth can ulcerate with lots of sugary ‘sports foods’ – keep eating proper food and swill mouth with water regularly (toothbrush in transition?)
8. Drugs- athletes must use pain relievers with caution. Do not take ‘just in case’. If pain or swelling develops, then start with 2  paracetamol tablets (up to total of  8 in 24hrs). Anti-inflammatories (NSAIDs) can be dangerous in dry, hungry people ie., multisport athletes in a race! To avoid stomach ulcers, vomiting/gastritis and kidney stones or failure (all occurred in 2016), keep drinking fluids (see #4) and eat when you are taking NSAIDs. Don’t mix different NSAIDs (ibuprofen, diclofenac, naproxen) on the same day. Additional pain relievers also to be used with caution- codeine and tramadol can cause bizarre ‘spacey’ feelings and even hallucinations especially as you will be physically and mentally under great duress
9. Eye protectors – sunglasses are essential for the ultra-strong NZ sunlight. In dim (no!) light, clear specs are advisable if bush-bashing or in forest, or even road biking with moths flying
10. Sleep monsters – deprivation of sleep makes your racing inefficient. Many top 10 teams plan for 2+ hour ‘power naps’ and also then manage to enjoy their race!

2017 (Chapter 6) Medical Report

Thank you to all those who managed to find time to answer our questionnaire last year. About a third of you completed both the ‘before’ and ‘after’ survey, and another 50 or so managed to fill in one of the surveys. However, the (lower) completed number of surveys (and some complications due to the design of the questions) proved insufficient to enable us to analyse the information by statistical means. We were however given some fascinating insights into multisport athlete behaviour, good feedback on your ‘wants and needs’ and a couple of warnings to be given to avert personal medical disasters on such races. This may well help you prepare for the up-coming GODZone and we share these findings below.

Pre-race preparations

Training hours: you reported training between 6 and 30 hours per week – median number of hours trained was 15. I had limited data from top athletes (under 4 days completion) – 8 hours for one, 19 & 20 hours for 2 others. For most other questions, 7 top athletes seemed to have comparable preparations/medication use/injuries/after–race-symptoms to the general field.

Procedures used in pre-race weeks: many reported using antichaffing creams (eg Gurney goo) for body/feet, antifungals for feet too, foot taping, massages, vitamin use, hardening of feet (mainly by endurance exposure, long tramps, but some chemical dips!!), tapering of exercise close to the race with extra sleep – though some also tried accustoming the body to sleep deprivation on training weekends!

Pre-race injuries: similar to those reported in the race – see above

Pre-race illness: lots of common colds/chesty coughs reported (people over training, not rested enough before a long race?)

Injuries/medical problems

‘What the doctor saw’ & what you reported in 2017, listed in approximate order of frequency

Feet: most of you reported some problems, from minor blisters to toenails ‘floating off’ painfully, raw and red patches, to complete (WW1 era) trench feet, where skin was peeling off in strips. (Dr’s note – This year we felt trench foot was much reduced compared to previously. Perhaps many athletes took heed for the information sheet on ‘preparing the feet’ for this rugged race. Also likely, was the uptake of dousing with dilute (pink) potassium permanganate solution (Condy’s crystals) -120+ doses of ‘sheep dip’ given!! This has been shown by research to kill off the ‘trench foot’ bacteria and fungi. Medics noted only 37 ‘severe’ feet this year – all daubed with iodine but occasionally also needing oral antibiotics.)

Infections: common! (Dr’s note-the immune system is known to be suppressed by high activity/fatigue/dehydration). Minor skin cuts became septic and some cases of pneumonia occurred (common viruses escalate into severe bacterial infections under ‘race’ conditions’.)

Sprains: of joints- wrists/ankles – and muscle strains (ITB/forearm/lower shin & ankle)

Skin tears: (some very deep) – shins/forearms/bike ‘gravel-rash’ abrasions.

Chaffing: of feet/trunk/butts/’undercarriages’/mouths

Gastritis: vomiting episodes with some upper tummy pain (Dr’s note – It was unclear what caused this especially early in the race when infection seemed unlikely. Stress (physical and mental) may have been part of the picture. Taking a specific stomach-protecting pill during the race may well help this? (eg omeprazole)

Diarrhoea: See later, especially with respect to the possiblility that some of the medications you used may have contributed to this frequent symptom

Medication adverse effects: Problems due to overuse of various ‘over the counter’ medications- specifically stomach (gastritis and even dangerous ulceration) AND kidney damage was felt to be largely due to (NSAID) anti-inflammatory pain-relievers ( more below) +Possibly some hallucinatory effects of other pain drugs (codeine/tramadol) under the duress of the race.

Impacts: broken bones/concussion (head injury)/bruises – ‘par for the course’?

Wasp stings, sleepmonsters

Eye injuries: corneal abrasions and minor scratches (Fortunately none so bad as in the previous year when an athlete perforated his the eyeball from gorse bush-bashing & he was pulled off the course for sight-saving treatment! )

Sunburn: frequent sunblock reapplication is highly recommended in the race!

Poor fluid or food intake with dehydration

Skin rashes of various kinds – sweat/allergy

Puffy limbs (oedema) – various causes; see section on low sodium/NSAID/muscle damage

Important safety info from Dr, as we noted many athletes using pain relief especially multiple NSAIDs

Many of you reported frequent use of non-steroidal anti-inflammatory tablets -NSAIDs- often 2-3 different types in a single day, including ‘slow release’ and ‘instant action’ types. (some drug names are ibuprofen, nurofen, voltaren, diclofenac, naproxen, naprosyn, celebrex, and indeed even aspirin is another type of NSAID -should not be mixed on the same day ). It seems folks were often not clear as to what tablets they were carrying and when they could combine different medications ( ie codeine/paracetamol/tramadol/NSAID) for enhanced pain relief. NSAIDs should be regarded as plain pain relievers (not really having ‘anti-inflammatory’ properties for most injuries). They also have specific hazards for all athletes stressing their bodies in Godzone conditions. ie

• stomach-lining/gut irritation ( doubtless NSAIDs caused many cases of vomiting we saw; one athlete developed a stomach ulcer and even those common race mouth ulcers may be triggered by NSAID use). Protection can be provided for the stomach during the race by taking a one daily dose of a ‘stomach liner-healer’ – omeprazole/pantoprazole/lansoprazole ( all proton pump inhibitors-PPI) NB ranitidine or antacids like gaviscon are NOT protective for ulceration, but are soothing!
• kidney damage- dehydration entailed during the race + use of NSAIDs will severely stress your kidneys. As a rule of thumb, follow the hydration guide below ( in hyponatraemia section).

The race doctors may recommend NSAID use for short periods, and only while ensuring good hydration. They are the first-line treatment for tendinitis pain and swelling eg in wrist/forearm after kayaking; front of ankle after long downhill treks; some knee injuries. NSAIDs are not to be used as blanket treatment for   perceived inflammation eg if your hands swell or for skin infections with swellings. Ask the medics at transitions for advice if you plan to use medications regularly- or better, ask your GP beforehand.

Hyponatraemia or ‘low blood sodium’

After imploring all athletes to keep well-hydrated, there is a nasty twist to the tale. Too much drink can be harmful. Studies on US troops carrying heavy packs in the hot desert, noted collapse (with some deaths)!! The cause was OVERDRINKING and NOT dehydration.  Athletes should be losing a little weight on course. Weight gain suggests overhydration and likely hyponatraemia. Swelling of limbs (oedema) can be due to low Na (more common) OR sometimes due to muscle damage/breakdown during race.

List of symptoms caused by low sodium is alarming=Rapid weight gain; Bloated stomach; Swollen hands and feet; Nausea & vomiting; Throbbing headache; Dizziness;  Severe fatigue; Lack of coordination; Restlessness; Confusion & disorientation;  Wheezy breathing; Seizure; DEATH!

Bottom line – Athletes= should be told to ‘drink to thirst’. ( NOT to PUSH FLUIDS, nor ‘PRELOAD’) and to take electrolyte mixture (many brands are often still a little hyponatraemic ie short on sodium) – but don’t add salt tabs as these may increase thirst and hence worsen fluid overload with low Na. Eating saltier foods is a good idea on a MULTIDAY race like GZ.

In GZ’s hot, strenuous mountainous conditions, then 700mls to 1 litre per hour for 6-8 hours stretches is unlikely to cause low sodium and will protect kidneys from dehydration. Note: frequent use of NSAIDs (extremely common amongst you athletes – see section above) can markedly lower sodium level and is another reason to steer clear of them.

After the race, athletes with weight gain +oedema who feel reasonably well,  ie none of the severe symptoms above, can expect to pass a lot of clear urine over the next few hours, to days, and their low sodium will self correct. During this recovery, having hypernatraemic (higher sodium) oral intake can help eg oxo cube/bovril in 125 mls water.

Race body stress/immune suppression

It is well known that endurance events like GZ cause marked changes in your body metabolism and processes. The immune system can be affected – reducing protection against simple infections- and this is thought to be why so many fit athletes develop nasty skin infections as the race goes on, or why a simple viral cough can turn to bacterial pneumonia (cases this year and last!), or even why a NSAID drug can more readily produce a stomach ulcer in athletes. We are not sure how to protect against these processes. It is important to treat such ailments as scratches/abrasions and foot infections fast and early to avoid spiralling problems. Many athletes reported using ‘complementary therapies/health shop products/supplements’, but the evidence for benefit (on immune resilience or race prowess) is largely unproven.

Products used

You reported taking a startling number of meds / complementary therapies. AND NOTE, ALL therapies, however ‘natural’, can have unintended (side) effects. Diarrhoea can be caused by many of the potions taken by athletes- eg NSAIDs, caffeine, eating lots of chewing gum (from the laxative effect in sorbitol sugar-free sweetener), magnesium ( supposedly to counter cramp). Thus anti- diarrhoeal tablets used by some racers may just be an antidote to the effect of another medication! Of course, diarrhoea may also be due to GI infections, or just the body stress of racing which stimulates bowel action.

See aforementioned NSAID hazards to gut/sodium/kidney. You used:

• Commonly – Antichaffing creams (eg Gurney goo) for body,feet ,Electrolyte, Caffeine, Pain (NSAID) reliever, vitamins of various ilk, Magnesium, Poassium Permanganate ( 150 + athletes)
• Less commonly – Paracetamol/Tramadol/Codeine, Anti Diarrhoeal (loperamide), Mouthwash/Brush, Race taping – Ankle/Feet/other Tape, Sports Meals Gastro protection (see above omeprazole)
• Rarely – Iodine, Topical, Vitamin C, special socks, Iron pills, Glucose, Chia, Antihistamine, Asthma inhalers, Bonjela- ‘teething/ulcer gel’, Sports Supplement, Antibiotic cream, Antibiotic tablets, Salt, Protein, AntiNausea, Gingko, Herbal pills, AntiOxidants, foot powder, sleeping pills, blackcurrant tabs, beetroot

‘After race’ symptoms

Almost every athlete reported at least one of the range of symptoms we asked about, in the days (to occasionally, weeks) following GODZone:

• Commonly – general fatigue, foot swelling, hand swelling, tingling or numb feet, mouth ulcers, night sweats, broken sleep
• Less commonly – painful feet, gastro reflux, heart palpitations

(Dr’s note -At least one athlete implored us for this ‘info on what issues are likely to be experienced after finishing for first time athletes so that they are aware that oedema, painful feet, sleep disturbance is ‘normal’’.)

Dr Lynne John    Dr Rhys John