Tuesday, April 21, 2015

Runner Pees Red- Now What?

Runner Sees Blood in Urine: now what?

Kona Lua: "Get A Head"

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

Ever looked into 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 Virginia runner I’m familiar with, 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, for reasons specific to this individual, 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.  And, like many other things we see happen to our athletic group from runner’s trots to plantar faciitis, in my experience, I’ll see a lot of people with these things once, and then never again.

We both hope.

Thursday, April 16, 2015

Balance in Triathlon; Do You Respect Your Injuries?

"I always wanted to be somebody. Now I realize I should have been more specific!"  Lily Tomlin

Respect your injury.

Most triathletes are psychologically stronger than they are physically.

Many athletes focus on training related injures involves solely whether or not they’ll be affected in an upcoming race.  Little thought is given to making injury resolution priority #1.  They've sought help from a friend, an internet forum, or local medical professional. But in the end, many realize they've invested so much time and energy as part of this sport, there's a good chance they know more about themselves athletically than any physician.  Although this is likely not true medically, this gives them an insight into helping their care giver help them. It's a pretty unique patient-doctor relationship that as a physician I don't see all that often but one I enjoy.

Brett Sutton, famed tri coach, views it this way: "injuries are nothing more than a test of character.  You see quickly how they deal with adversity.  Injuries go but the scars remain in the minds of most." (Sutton's comments leave me wondering if those are positive or negative scars.)

The take home message here is that we will all be injured at one point or another, some of us frequently, some of us annually, some less.  You know that all of us get a great deal more out of of triathlon than finish line times.  Although you've heard this before, you can't hear it often enough.  Listen to your body.  Most triathletes us are stronger psychologically than physically!  Really.  And I think you know it.  (For those of you old enough, does the name Gordon Liddy, organizer of the Watergate burglaries during the Nixon administration, mean anything?)  If we have the potential to do things to ourselves in the name of fitness, we have the potential to undo them as well.

Monday is the "most commonly injured" day.  It's not actually. It's just the day that people complain of pain the most. "I don't understand it. I just ran my usual 5 miles this morning."  What they don't see is that it may have taken a couple days for the effects from Saturday's big brick workout to become apparent.  I see it all the time.

  Take local athlete Mark Foley.  He is a master at achieving a sense of balance between offspring, job, triathlon and just plain enjoying living that many strive for but few of us achieve. You know how when you're talking with one of your tri friends, (or perhaps someone talking to you? Am I getting warm here?) and it becomes obvious that your idle chatter is cutting into their work out time? And they start to fidget? And then fidget a little more? And if you talk to them too much- "well, my T1 split at his race was 2:33 but at the next one it was..." they go into a full grand mal seizure? Yeah, I thought you did. It reminds me of one of those Whack-A-Mole games.........

Mark doesn't do that, ever. He has this sense of calmness, of control, that everything's going to be OK.  I think this is because he sees triathlon as a part of life, but not life itself.  Like many successful athletes, he's learned to utilize the darkness.  He plans work outs around work and life instead of the opposite, even if this means getting that morning work out done before heading to the lab, it gets done. Achieving this morning competence can be quite valuable since when you're the first one up, you can get in a run and wave to the deer and the newspaper guy.  Or, some time on the trainer with Phil Liggett and Paul Sherwin distracting you with previous TdF dvds.  My swim group meets at 5:30.  In short, you can get in some quality training and be done when others are just stirring.

I had someone tell me once that they'd think twice before hiring some one deeply involved in this sport.  Sure, the old adage about giving something you want done to the busiest person you know is part of this but do they think, plan, drown in triathlon during their work day to the point that it diminishes their effectiveness....

I, as anticipated, disagreed strongly knowing that a triathlete is a master of the clock.  To quote my fellow Ironman.com writer Lisa Dolbear when asked about time management:

"I could do a tri, I just don't have the time."
News flash: We don't have the time either, but we've found a way to carve it out of our busy lives because that's what you do when you commit to something important to you. Thirty-five year old mother of two, part-time MBA student, community volunteer, fitness instructor and full-time marketing professional Darcy DiBiase is no stranger to busy schedules. She’s also no stranger to triathlon. "I learned how to own my world at 5:30 a.m., and use the time before everyone else’s day started to do things for myself," the three-time Iron Girl finisher says. "And time is only one of the resources I needed to be successful—I’ve also found the right people along the way to keep me motivated and committed to my goals."

That's right, stay committed to your goals!

Sunday, April 12, 2015

One Shallow Dive Can Wreck Your Neck!

Diving Safety

I remember my first time.  The first time in my residency I was called to the Emergency Room of the University Medical Center to see a young man who'd broken his neck and become instantly paralyzed.  For life.  His name was Carl and in happened in shallow water about an hour away from the hospital.  I'd never put a patient in cervical traction, a halo, before and it wasn't easy.  You feel so bad for this young person who's life was filled with such promise when he got out of bed this morning.  The halo is a ring of steel which looks a little like a wedding ring, only 8-10" in diameter.  It's attached to the patients skull just above the eye brows with threaded screws which pierce the outer table of the skull.  Yep, it's screwed directly into their head.  Life as they know it is over. 

“Each summer, orthopedic surgeons see emergency room patients who dive head first into shallow water, break their necks, and are paralyzed,” said Richard S. Siegel, MD. That’s one reason the AAOS/ASIA public service ad warns, “One shallow dive can wreck a neck. Permanently.”  This is especially important to triathletes who, as the weather warms, find themselves hot and sweaty, often in unfamiliar places.
In one ad preaching diving safety, a glowing sunset spotlights a young swimmer as he dives, head-first, into a mountain lake. But instead of blue waters, the lakebed is filled with jagged rocks. The copy reads: “Each year, hundreds of young people are paralyzed from neck and spine injuries caused by diving head first into shallow lakes and pools. Don’t let kids dive in—unless you know what’s below. Check our website for more diving safety tips.” A link toOrthoInfo.org/DivingSafety and the CSRS/ASIA/AAOS logos are also shown.
Nearly 26,000 individuals are treated in emergency departments, doctors’ offices, and clinics for diving-related injuries in the U.S. each year, according to the U.S. Consumer Product Safety Commission. Approximately 800 of those injured—primarily teens and young adult males—are paralyzed due to diving in water that is too shallow.
“Their friends pull them from the water because they are unable to move their arms and legs and can’t breathe. Knowing when and how to dive safely prevents these catastrophic injuries,” said Dr. Siegel. He advises going feet-first if swimmers are uncertain of the water’s depth or if diving into water that is less than twice the swimmer’s height.

So if you're hot and sweaty in an unfamiliar place, and that pond you've just passed looks most inviting, please suppress the urge to dive in and cool off.  You never know what's below the surface.

Words to live by.

Sunday, April 5, 2015

Losing is Good For You

"When the guy kissed her, Cassidy felt a stab of pain that was close to physical, and therefore within the penumbra of hurts he told himself he could bear."

                                    Once a Runner, John L. Parker, Jr.*

In the shadow of a champion

Although the following is written from a somewhat different perspective, it's applicable to all athletes in this sport.  What is the role of the finisher's medal in adult sport?

Losing Is Good for You
                                                                By ASHLEY MERRYMAN

LOS ANGELES — As children return to school this fall and sign up for a new year’s worth of extracurricular activities, parents should keep one question in mind. Whether your kid loves Little League or gymnastics, ask the program organizers this: “Which kids get awards?” If the answer is, “Everybody gets a trophy,” find another program.

Trophies were once rare things — sterling silver loving cups bought from jewelry stores for truly special occasions. But in the 1960s, they began to be mass-produced, marketed in catalogs to teachers and coaches, and sold in sporting-goods stores.

Today, participation trophies and prizes are almost a given, as children are constantly assured that they are winners. One Maryland summer program gives awards every day — and the “day” is one hour long. In Southern California, a regional branch of the American Youth Soccer Organization hands out roughly 3,500 awards each season — each player gets one, while around a third get two. Nationally, A.Y.S.O. local branches typically spend as much as 12 percent of their yearly budgets on trophies.

It adds up: trophy and award sales are now an estimated $3 billion-a-year industry in the United States and Canada.

Po Bronson and I have spent years reporting on the effects of praise and rewards on kids. The science is clear. Awards can be powerful motivators, but nonstop recognition does not inspire children to succeed. Instead, it can cause them to underachieve.

Carol Dweck, a psychology professor at Stanford University, found that kids respond positively to praise; they enjoy hearing that they’re talented, smart and so on. But after such praise of their innate abilities, they collapse at the first experience of difficulty. Demoralized by their failure, they say they’d rather cheat than risk failing again.

In recent eye-tracking experiments by the researchers Bradley Morris and Shannon Zentall, kids were asked to draw pictures. Those who heard praise suggesting they had an innate talent were then twice as fixated on mistakes they’d made in their pictures.

By age 4 or 5, children aren’t fooled by all the trophies. They are surprisingly accurate in identifying who excels and who struggles. Those who are outperformed know it and give up, while those who do well feel cheated when they aren’t recognized for their accomplishments. They, too, may give up.

It turns out that, once kids have some proficiency in a task, the excitement and uncertainty of real competition may become the activity’s very appeal.

If children know they will automatically get an award, what is the impetus for improvement? Why bother learning problem-solving skills, when there are never obstacles to begin with?

If I were a baseball coach, I would announce at the first meeting that there would be only three awards: Best Overall, Most Improved and Best Sportsmanship. Then I’d hand the kids a list of things they’d have to do to earn one of those trophies. They would know from the get-go that excellence, improvement, character and persistence were valued.

It’s accepted that, before punishing children, we must consider their individual levels of cognitive and emotional development. Then we monitor them, changing our approach if there’s a negative outcome. However, when it comes to rewards, people argue that kids must be treated identically: everyone must always win. That is misguided. And there are negative outcomes. Not just for specific children, but for society as a whole.

In June, an Oklahoma Little League canceled participation trophies because of a budget shortfall. A furious parent complained to a local reporter, “My children look forward to their trophy as much as playing the game.” That’s exactly the problem, says Jean Twenge, author of “Generation Me.”

Having studied recent increases in narcissism and entitlement among college students, she warns that when living rooms are filled with participation trophies, it’s part of a larger cultural message: to succeed, you just have to show up. In college, those who’ve grown up receiving endless awards do the requisite work, but don’t see the need to do it well. In the office, they still believe that attendance is all it takes to get a promotion.

In life, “you’re going to lose more often than you win, even if you’re good at something,” Ms. Twenge told me. “You’ve got to get used to that to keep going.”

When children make mistakes, our job should not be to spin those losses into decorated victories. Instead, our job is to help kids overcome setbacks, to help them see that progress over time is more important than a particular win or loss, and to help them graciously congratulate the child who succeeded when they failed. To do that, we need to refuse all the meaningless plastic and tin destined for landfills. We have to stop letting the Trophy-Industrial Complex run our children’s lives.

This school year, let’s fight for a kid’s right to lose.

Ashley Merryman is the author, with Po Bronson, of “NurtureShock: New Thinking About Children” and “Top Dog: The Science of Winning and Losing

* If you haven't read it, it's a must.  The pure essence of training.

Tuesday, March 31, 2015

How to Find a Great Sports Med Doc

- What are you doing?

- Just wondering who's the best.

                                                     Top Gun

I was flattered when asked by Joe Friel and Jim Vance a couple years ago to write a chapter for their book Triathlon Science.  It's a good reference text if you don'e own a copy. The publisher describes it as "Leave ’em in your wake, leave ’em in your trail, leave ’em in your dust. Get your brain as fit as your body and achieve your triathlon potential." 

One of the points I tried to make was to have an "injury resource team" in place before you are injured so that your down time is minimized.  One of the key pieces of that team would be a doc who understands the needs - and differences - of the athlete.
Don't be embarrassed to ask around now to see what's available, who's available.  It very much might not be the local football team doc or orthopedic surgeon, but someone who's just off your radar screen for now.  Help could be right around the corner in a place that you might ordinarily not look.  As the Boy Scouts say, Be Prepared.

Bill Vollmar, MD perfect sports doc

"Son can you play me a melody, I'm not really sure how it goes. But it's sad and it's sweet and I knew it complete when I wore a younger man's clothes."           Billy Joel

OK.   You didn't have injury concerns until you signed on to this crazy triathlon thing.  Now you might need to seek medical help one day?

Triathletes are what's known in MBA circles as early adopters.  They'll try things (anything you ask??)  such as compression clothing, Biestmilch or kinesio tape, often with minimal proof/history that the new product/technique is actually beneficial..... but it might be.  An example might be the following: you're on one of the tri forums, and a poster complains of some variety of musculoskeletal problem.   Invariably one of the "expert" responders - regardless of stated problem or knowledge base - notes the "obvious" indication for ART (Active Release).  Well, ART may be helpful in the right setting but the nearest practitioner here according to the ART web site is almost two hours from my house.

A recent Men's Health magazine has a piece entitled, "Doubting Dr. Google." The magazine's cover directs you to The World's Worst Doctor, (turn to page 100 and cough, making the point that "a little medical knowledge can a dangerous thing, which makes the Web a virtual minefield."

The two photos above are of Bill Vollmar, MD, seemingly "only" a Family Practitioner from
Lancaster, PA and some might think he'd have trouble spelling triathlon.
But he is whip-saw smart, takes care of almost exclusively athletes, and since
unlike me he's not a surgeon, would likely have a non-surgical solution to
almost any injury if it's feasible. Only as a last resort would he consider
involving someone who might want to cut on you!  

And, in my humble opinion, he is so good that he could
take care of me and my entire family. Including my 100 mile/week runner son.

And lord knows I've had more than my share
of musculoskeletal problems - compartment syndrome, plantar faciitis, Achilles
tendonitis, rotator cuff tear, I could on. The take home point is that, at least
for many of us, we don't have to drive or fly hours to the Pro from Dover with the
treadmill and infra red sensing system for a good portion of our medical needs, we just need to know what's available locally.  In fact, like many locations, the go to guy here for most
running related issues is the owner of the running shoe store. With over 30 years of
seeing runners problems, he could take care of the Olympic team! And I'll bet
there are examples of this in your community, possibly the kids swim coach who's been
working on swim strokes for decades for a shoulder related swimming issue.

Look for Primary Care physicians, FP's or Physiatrists (a doc who specializes in physical medicine and rehab), etc., men and women in your community who've earned the respect of the running/triathlon world as a care giver and have a major practice emphasis on sports related problems.  They don't necessarily need to be a member of the ACSM, the American College of Sports Medicine, but it's a nice touch.  It's been shown that a respectably high percentage of us are injured annually so simply doing your homework with the other folks at the pool or on the WE long bike ride may give you just the answer you seek.

Tuesday, March 24, 2015

Donut Swimming: Want to Swim Faster?

"Krispy Kreme Doughnuts, everybody loves them."

But from David Letterman  "I thought this was interesting, on the box, 'Konsult Kardiologist.'

Drooling just looking at them 
My first encounter with Krispy Kreme donuts was at the Pensacola Three Mile Bridge Swim about 15 years ago.  I had my first the night before the event.  And second, and third...you get the drift.  It was a wonder we could swim at all.  It's been a love affair ever since.

We used to have a Krispy Kreme Donut Shop near our house.  On weekends when you were driving with the kids, and the "Hot Donuts Now" sign shown from across the highway, it was impossible not to stop and watch the glazed donuts in the conveyor cooker as they slowly made their way to the end.  To each kids delight, the employee would skewer a hot, fresh one and hand it over.  Yep, not many things taste better than a ten second old donut!  And for just a few moments you're not concerned about how many calories in equals how much working out is required for reversal.  For a few sweet moments, it's just the best!

OK, back to swimming faster.  This was originally published a while back in one of the online swim mags.  It's called the Cone Drill in a piece written by David Marsh, former head coach at Auburn and Olympic Assistant Team Coach which I will publish in it's entirety.

This is especially important pushing off the wall where many of us create so much drag, surface prematurely, losing all the momentum gained from the turn.  It's a quick read.

The Donut Drill
Visualize swimming through a donut (cone) 

More plainly put, you need to diminish the drag you create while swimming.
 "To put it simply, if you want to swim faster,
you need to reduce the drag you’re creating in the
water. There’s an endless number of technical drills
one can practice to improve body position, timing,
and technique to reduce drag.
 But there are also mental or visualization
drills that swimmers should incorporate into their
practices. One of my favorites is the cone drill. In
essence, visualize the recovery of your stroke—any
stroke—as if you’re trying to squeeze your entire
body into a streamline position to swim through a
cone, from the large end to the small end.
For example, if you’re swimming breaststroke,
during your hand recovery, your biceps should be
tight to your ears and your head in a streamline
position as you extend forward, swimming through
the imaginary cone. For freestyle and backstroke,
extend each recovery stroke as far forward as
possible, allowing your body to find a streamline
position and squeeze through the imaginary cone.
 For swimmers who may not be able to rely
as much on pure strength to power through the
water and cover stroke flaws, improving body
streamline when swimming and when pushing off
the wall will reduce drag and lead to more efficient
and faster swimming. Next time you are swimming,
visualize that you’re trying to streamline your way
through a cone, from the large end to the small end."

Monday, March 16, 2015

You Don't Mess Around With Jim -Head Ironman Referee


You don't tug on Superman's cape
You don't spit into the wind
You don't pull the mask off that old Lone Ranger
And you don't mess around with Jim*
*If you happen to be in an Ironman that is!
Before the blog, first this about the enormous good done by Jimmy's team. 
2014 Race Across America Team Intrepid Fallen Heroes

 From Intrepid Fallen Heroes web site: In June 2015, Team Intrepid Fallen Heroes will compete in in Race Across America- a 3000 mile competitive endurance race- this year as a 4-person mixed team. In June 2014, Team Intrepid Fallen Heroes participated in the Race Across America winning the 8-person team division and raising $650,000 to support our wounded military heroes suffering from traumatic brain injury. The team races again this year with a goal of once more achieving victory and raising even more funds for our wounded troops. Please join us in this great challenge.
Refereeing an Ironman

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 2100 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 this 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."

There are other examples but these three illustrate the point. In 2015, 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 2100 children. Who knows. Thanks, Jimmy. Thanks, Dad. But if you plan to stretch the rules, watch out, Jimmy's right around the corner behind you.

Images 1, 4 from Team Intrepid Heroes web site.