Sunday, April 13, 2014

Tobacco Related Events in the US, 1900-2014

                                                                                                      Mark Twain

Hard to believe but there are those among us that train by day and smoke by night.  Like anything that's an addiction, once started, even though the desire to race quickly is strong, the grip of the addiction often wins.  Like many of you, I started smoking in HS.  By the time I was a Marine Helicopter instructor in Pensacola, FL smoking was part of my nature at 2-3 packs a day.  
However, after getting rejected by 9 medical schools the first year I applied, I made a deal with myself that if I got accepted second time around I'd pay a significant price - stop smoking.  From the instant I opened the acceptance letter to the University of Miami School of Medicine so many years ago, I haven't had a cigarette since.
Maybe we just need the right motivation.  It's human nature. 

Smoking sucks! The one thing I would say to my kid is, 'It's not just that it's bad for you. Do you want to spend the rest of your life fighting a stupid addiction to a stupid thing that doesn't even really give you a good buzz?'
                                    Katherine Heigl

Tuesday, April 8, 2014

Flying After Racing? Watch Out For Blood Clots

"I think it is just terrible and disgusting how everyone has treated Lance Armstrong, especially after what he achieved, winning seven Tour de France races while on drugs.  When I was on drugs, I couldn't even find my bike."  
                                                                       Willie Nelson

Many of us fly some distance to an event, race, smile, get a finishers medal or better, pack up and head to the airport.  This can be a dangerous strategy.  Despite being in peak condition, we may be little dehydrated (or a lot dehydrated in some cases - ring any bells here?) and this puts us at risk for developing deep vein thrombosis (DVT), or blood clots in the deeper veins in our legs.  Although these may cause us mild pain or leg warmth, occasionally there's calf swelling, but in many cases little to no symptoms. According to WebMD, When you have a deep-vein thrombosis (DVT), you need to treat it to avoid a life-threatening complication: a pulmonary embolism. A pulmonary embolism (PE) usually happens when a blood clot in the leg breaks away, travels to the lungs, and blocks a lung artery. It can damage the lung and other organs and lead to low oxygen levels in the blood. It can even be fatal!

In short, DVT can be a big deal, and like the other medical issues you had no knowledge of prior to starting this sport, like hyponatremia, understanding how to avoid DVT and it's related problems is the winning way.

First, start that re hydration in earnest before leaving the race course and continue until you are urinating again and it's light yellow.  Experienced competitors already know that depending on the conditions this make take some effort.  In an earlier blog I mentioned talking with one finisher after the race at Splasher's Restaurant located at the finish line in Kona (Thanks for the beer, Inde) who said he'd had several glasses of fluid post-race, more to drink in the condo, and two beers at Splasher's - not one, two - before we started chatting. So after what amounts to nearly 100 ounces of fluid replacement, he still had no urge to pee.

If you have some of those knee high compression hose, put them with your post-race clothing so you know to wear them on the jet home. And even though you may prefer that window seat to rest your head against the bulkhead and nap, grab an aisle seat this time so you can get up and move around frequently.  It keeps the muscles in your calves contacting and the blood flowing throughout your legs.

Note right calf appears larger than left calf from behind.

Although the development of a DVT and subsequent PE is fairly rare, I've seen it in my patients enough time to have great respect for the process.  One only needs to check Slowtwitch or other tri forum and the number of athletes who've suffered a DVT is surprising!

Those who are obese, have a blood clotting disorder, take birth control pills, are pregnant or smoke are at greater risk. If you can remember a few of the symptoms you'll be half way.  As noted above, these can be non symptomatic but then again you may notice a little calf swelling, perhaps more on one side than the other.  Or, an unexpected leg cramp. Similarly, a pulmonary embolism can be asymptomatic but frequently there's chest pain, shortness of breath, coughing up blood and a feeling of rapid heart beat or sudden sense of doom.  If this description ever fits, it's an emergency and you need get immediate medical attention.

Excellent Resource:

Saturday, April 5, 2014

How to Breathe on Both Sides/Unbridled Enthusiasm for Triathlon

"...she's bright as a button and kisses like a nymphomaniac on death row."
                                                                      Notting Hill

Although this comment was addressed to Hugh Grant about an upcoming date, are you this enthusiastic about your sport? I hope so.  Triathlon can yield significant health benefits, a sense of  well-being and perhaps even a little weight loss in motivated athletes.  USAT has over half a million registered triathletes all smiling just like you as winter turns into summer and racing is here!

Lynne Cox in action.

If you can't breathe easily on both sides, you're simply a Stone Age triathlete.  The reasons to master this skill are many.  Safety for one. If you look both right and left while you're in open water, you'll be aware of other swimmers, maybe a boat or two and have a powerful, balanced, faster stroke. How can you make your best racing turn around a buoy on your left if you only know how to breathe on the right?  I doubt you can.

Often you'll encounter a little chop or some small waves crossing your swim course.  You can keep the back of your head, and your open mouth seeking air but sucking air and water, to the wind and waves if you know how to breathe either to one side or the other.  Most successful racers do.

Lynne Cox, author of the Open Water Swimming Manual, and a swim career that includes twice setting the record for fastest crossing of the English Channel, has a few easy paragraphs that may make it a little easier for the self-coached athlete.  If it's still a challenge in your local pool, a couple sessions with the swim coach may be all you need to get over this hump and never look back.  But to look to the right and left, though.

One note of caution.  When attempting something new, it's very easy to try it for two minutes, mess it up, and say "Oh well," returning to ones previous flawed technique.  This will prove a challenge to you, one I learned 20 years ago at one of the Total Immersion Swimming weekends.*  So give it some time, maybe just a few minutes on day 1, but keep at it.  The rewards greatly exceed the awkwardness of learning something new.

Bilateral Breathing Drill from Lynne Cox

-In the pool, lie on your right side, as if you are going to swim side stroke, with your right arm extended above your head and the other arm resting on your side.
-Put your face in the water and blow bubbles.  Take a breath when needed.
-Kick six to eight times on your side.
-Take a stroke with your left arm and use the core of your body to roll all the way over to the other side of your body.  Make sure you are using your core to roll over.
-With your left arm extended, let your right arm rest on your side as you kick on your left side six to eight times with your face in the water.
-You want to maintain a straight line in the water.  Usually, swimmers are more balanced on one side than the other.  Sometimes it takes a little more concentration and work on balance to kick on one side as opposed to the other.  But this exercise will help you balance your stroke and also swim in a straighter line.  It is easy to see which swimmers in the open water have a balanced stroke.  Those who are not balanced will swim in the direction of their dominant side, off to the right or left, and not maintain a straight line.
-This drill will also help you maintain a horizontal position and enable you to move efficiently through the water.  You will be rotating from one side of your body to the other reinforcing that your arm stroke is done in conjunction with the rotation of your body, so that you are pulling with your core as well as your arms.  If you do not use your core with your arm strokes, you will not swim efficiently.  You will be swimming flat on the water, and if you are using only your arms, the muscles in your arms will fatigue more rapidly and you will tire sooner.
-This drill will also help you increase your power, speed and endurance while you are swimming.


Thursday, March 27, 2014

Accepting Thank Yous. Athletes Are No Good At It

The Grateful Patient (or Triathlon Race Fan)

Ironman race fans line the course, waiting

“….he did not know how well he sang, he only heard the flaws.”

                                            Martin Tanner by Harry Chapin

My wife had, in her office recently, a patient whom she’d referred to me 18 years ago for a total knee replacement.  This most significantly obese, manic depressive woman who raises prize winning Labrador Retrievers, of which we have two, noted that after nearly two decades of punishing this knee that it was beginning to give her problems again.

 But, when my wife shared this with me, rather than thinking how much good use this patient had gotten from her prosthesis or that eighteen years was incredible in this situation, two opposing thoughts arose.  When surgeons receive unrequested follow up on a patient regarding something they’ve done in the past their first thoughts are negative.  Unforeseen side effect in our litigious society.  Infection, peri-prosthetic fracture, pulmonary embolism, did I do something incorrectly, and the like.  All glass is half empty stuff.  And when this patient was discharged from my practice many years ago, she was overwhelmingly grateful.  Grateful to the point of tears.

 Perhaps like a rock star used to, conditioned to, acclimated to adulation, we as physicians receive thanks from patients on a daily if not hourly basis and we may occasionally lose sight of the differences we have made in people’s lives.  Our patients offer genuine, sincere appreciation of our help without the expectation of secondary gain.  Successful endurance athletes, to a degree, are the same.

Has the passage of time, and 1,000 thank yous, or race fans cheering "You the man" numbed us to the automatic?   If we look around at our triathlon peer group and see this common response to being cheered do we erroneously think, as Joe Walsh sings, “…everybody’s so different, I haven’t changed…lucky I’m the same after all I’ve been through.”  When you fly down the finishing chute of an Ironman, and the fans want to high five you - yes you - do your own personal thoughts, possibly embarrassment, preclude you from enjoying the moment?  I think the answer is, to some degree, yes for all of us.

 I want to share with you a remarkable letter written to a Primary Care friend of mine who wasn’t even the author’s doctor but a chance medical encounter changed her life forever. You have the same opportunity every time you race, to every child on the race course, many of the adults, and that volunteer in the changing tent who's total focus is you.

Dear Doctor _____

      I am hoping I have contacted the same physician who had patients at Sandy Ridge SNF 2004.   I was a CNA there during Hurricane Ivan in September 2004.  I was working a night shift when I asked you about liver tests because I had overdosed February ’04.  You might not remember me but I will never forget you or lose my gratitude for your advice.  It was obvious I was depressed at the time.  I know I told you I was self-injuring and my friends I was staying with hid their knives.  You said I needed friends like that.  Your advice was to go running; it would help me put color back in my world.  I took your advice and began walk-running.
 September 2006, so two years later, I ran my first marathon and had been out of depression for some time.  A few weeks ago, my husband and fifteen month daughter old and I went to Chicago for me to run my first ultra-marathon, a 50K.  I have also run 9 marathons and feel so much better.  I earned my masters in Speech Pathology ’07 and work on Saturdays in a rehab hospital and during the week I stay home with my little girl.  I know our interaction was very brief but running has saved my life and I thank you for listening and your wisdom.

God bless, Julie ___________

Although letters like this are infrequent, gratitude is not.  Try to take that extra minute to savor peoples appreciation of your triathlon efforts before putting the force shields back in place to do battle with the pain of racing.  Your efforts provide the roll model for those in our society who will not or cannot exercise the way you do.  Although it's a role you only find yourself infrequently, it's one you need to play.  At the end of your career, the grateful patient (or race fan) stays with you.

I’m sure.

IRONMAN Parade of Nations for the fans in Kona.

Big Island Athletes get a special ride in the Parade of Nations.

Thursday, March 20, 2014

Stress Fractures, Yes It Can Completely Break!

Well, I'm running down the road 
Tryin' to loosen my load ..........

I got 7 races on my mind.  

Four that wanna drown me,

Two that wanna crown me, 

one says it's a friend of mine.     The Eagles, Take it Easy 

Jones Fractures 

Although foot fractures, specifically those of the fifth metatarsal, are most common in the cutting sport athlete like basketball or soccer, they do occur quite frequently in the triathlete population.  A fair amount of confusion exists between the common simple avulsion fracture (where the end of the bone is pulled off by the strong peroneus brevis tendon, displaces little, and heals readily with a short period of immobilization,) and the more serious injury where the unlucky triathlete suffers the so-called Jones fracture, one that is infamous for non-union and poor healing.

Sir Robert Jones, a noteworthy physician who practiced over 100 years ago, described what we now call the Jones fracture  having it occur in his own foot. He injured it while dancing around a tent pole at a military party.  He described it as an injury to the bone about three quarters of an inch from it’s end occurring as he “trod on the outer side of my foot, my heel at the moment being off the ground.”   Interestingly, x-ray was only invented 7 years before his injury.  (Initially, exposure time was 2 hours!)

This group of fractures has come to be divided into three types beginning with the relatively common, simple avulsion injury secondary to ankle inversion (like a typical sprained ankle) with no antecedent pain history.  These injuries are usually straight forward and can commonly be treated with a short period of immobilization such as a cast. 

The second type is the most common, a stress fracture which actually breaks all the way through.   Although it’s an acute injury, the athlete when queried will admit to some pain in this region before hand.  This may be somewhat surprising to the reader who may have had an extensive experience with stress fractures in his/her training world but is not familiar with them going on to completely fracture.   Not infrequently, they’ll also displace.  Although if given enough time, this second type will usually heal, but the possibility of the lack of union is high enough that many athletes with this fracture will choose surgery.  This surgery would commonly involve realigning the bone fragments and placing a long screw down the center of the bone.  Surgery requires anesthesia, and, the foot must be immobilized for several weeks post-op.

The last, and worst type of bony injury to the upper 5th metatarsal, is a long standing non-union fracture. It just doesn’t heal. These can be treated with metal screw fixation and bone grafting.  Some can be quite difficult to heal and have resulted in “career ending” injuries for some triathletes.  The take home lesson would be that if one has prolonged pain on the outside of the foot, in the vicinity of the fifth metatarsal, that having it checked out sooner rather than later can help the type A triathlete avoid serious and perhaps devastating injury.  A simple examination including x-rays is all that’s needed for early detection and most likely reduce the potential for a long standing non-union fracture allowing for a non-surgical recovery.   Dr. Jones did not comment on his personal treatment or it’s eventual outcome other than to note in his case “the disability lasted several weeks.”  Looks like he was pretty lucky.  You may not be.

Image #1, Themetapicture

Monday, March 17, 2014

Transition Obstacles -& The Miracle of Triathlon/Running

Gonna tell you a story that you won't believe
But I fell in love last Friday evenin'
With a girl I saw on a bar room TV screen.

Well, I was just gettin' ready to get my hat
When she caught my eye and I put it back
And I ordered myself couple o' more shots and beers.
                                                                                                Jim Croce

If you'd been watching the record setting performance of Australia's Mirinda Carfrae while sitting at Splasher's Grill on Alii Drive, 100 feet from the Ironman finish in October, and you saw this "A" level athlete powering through the marathon finish, ready to take her second World Championship break, and her own course record in the process, you'd put your hat back too!

You gotta love Mirinda Carfrae.  You just do.  Here's a gal who runs a 2:50 marathon after swimming 2.4 miles and riding her bike 112 miles.  She puts in the third fastest run of the day, third of all comers, beating every other woman, and all but two of the men!  Plus, she's recently married a fellow Naval Academy grad.

Go Rinny!...And good luck to you and Tim. We can't wait to cheer you both on again.

Transition Obstacles

And you let a little thing like this slow down your transitions?
I first used this photo in a must read blog on transition improvement last Spring, As we in the North and East are on the cusp of the racing season it would make and excellent review.  The concept is simple.  You may not be the fastest biker in your age group, but if you're the quickest at transitions, you may not have to be.  All it takes is a little practice and you can reduce transitions to practically nothing.

Miracle of Triathlon/Running

Lastly, we all get something different from our sport.  Some athletes aim for weight loss, some a certain level of fitness and still others yearn for the thrill of competition.  We all benefit in some way as we're slowly exiting the weekend race site, numbers still marking our arms and legs, finishers medal round our necks.

But one of my med school chums shared the letter below (slightly modified to protect the identity of the author) and you'll see gratitude for the sport in a way that you might not have imagined.

Dear Doctor _____

      I am hoping I have contacted the same physician who had patients at Glenside SNF 2004.   I was a CNA there during Hurricane Ivan in September 2004.  I was working a night shift when I asked you about liver tests because I had overdosed February ’04.  You might not remember me but I will never forget you or lose my gratitude for your advice.  It was obvious I was depressed at the time.  I know I told you I was self-injuring and my friends I was staying with hid their knives.  You said I needed friends like that.  Your advice was to go running; it would help me put color back in my world.  I took your advice and began walk-running.
 September 2006, so two years later, I ran my first marathon and had been out of depression for some time.  A few weeks ago, my husband and fifteen month daughter old and I went to Chicago for me to run my first ultra-marathon, a 50K.  I have also run 9 marathons and feel so much better.  I earned my masters in Speech Pathology ’07 and work on Saturdays in a rehab hospital and during the week I stay home with my little girl.  I know our interaction was very brief but running has saved my life and I thank you for listening and your wisdom.

God bless, Alice ___________

So tomorrow when your run or swim is a little more challenging than you'd planned remember this letter. Remember this woman, and think about the positive influences you as a triathlete have on the lives of those around you, especially the children.  You put color back in peoples lives!


Image 1, Google Images

Thursday, March 13, 2014

Surgery, Even Athletes Have Operations

Surgery, What If I Need It?

American Tim O'Donnell causes a stir on Alii Drive in Kona
“You’re going to need to have that fixed.”

 “And then the surgeon walked out of the room.” If you’ve never had surgery, being told that the next step in your care involves a trip to the operating room can be a tad upsetting. What’s going to happen to me? How long will it take to get over it? Can I pay for it? Are you sure there isn’t another way to get better?  Hey, I forgot, I’m a triathlete, I can get through anything!  I’d better check with the Dodger and Freaky Fred on the Triathletes Forum for a second opinion.  (So many athletes rely on opinions they get from anonymous sources on line.  In short, don't!)

These and a 1000 other questions run through the mind of the new patient as he/she’s been told, for example, that their shoulder will continue to dislocate while swimming unless something is done surgically to prevent it.  Although it seems difficult, maintaining control of your healthcare is important and having some idea of what questions need to be answered is essential!

Be prepared to discuss the nitty gritty details like agreeing on a date for the operation, where and what time it will take place, pre-op diet, what to wear, pre-op blood or lab work that might be needed, and all the little details that are so important to the patient. In our office this discussion often includes a video about the procedure that helps put the patient at ease. At this stage you’ll be asked to sign the first of several permits giving your consent for surgery.  In our exceptionally litigious society, this is the first document that you’ll see explaining the basic nature of what will happen to you and the basic risks that you will be taking. You’re giving the surgeon permission to do the operation understanding that positive results, while implied and hoped for, are not guaranteed. If you have any doubts, want a second or even third opinion, now’s the time to express that concern! You’re the one having the operation and you need to feel confident about your decision.  It doesn’t bother the surgeon at all if you say you need to delay the procedure to ask around.  In fact some docs actually encourage this. However, there are some operations that get better results when done early, (not delayed.) In my mind as a surgeon, it’s the informed patient who helps me achieve the best results.  We’re a team.

 You’ll also probably talk with your insurance company.  Sometimes you can be surprised  when you learn that the terrific office health insurance policy isn’t so terrific after all.  If things don’t seem right, ask questions.  If it looks like there may be a significant financial burden placed on you, ask about all your options.  Sometimes a monthly payment schedule can be set up for your portion.  And, if it looks like this is an amount out of proportion to what you can afford, don’t be bashful about asking the surgeon to do it for less.  You’d be amazed, particularly in a private office, at how many times the answer to that question turns out to be yes.

Your Day of Surgery

You’ll probably be directed not to eat or drink after midnight the night before to avoid any problems with anesthesia.  You’ll arrive at the hospital/surgicenter an hour or two early, change into one of those funny gowns that opens in the back (don’t worry, even though these gowns are pretty drafty, the staff is really not looking at you even if you think you have a hot triathlon bod – honest, they do this every day and it’s “seen one, seen ‘em all.”)  Then it’s time to meet the staff, sign more permits and prepare for your time in the operating theater.  Surgicenters are very efficient places and they like to stay on schedule.  Arthroscopic cases are usually very predictable time wise. The anesthesiologist discusses the options for anesthesia, helping you pick what’s right for you. In some cases the best option is to be put to sleep (general anesthesia.)  In other cases there’s an advantage to a local or regional block.  Your preference and those of the surgeon are taken into account.  There may also be an IV involved.  And when your turn comes, off you go into a whole new world.

For this article, let’s say you’re headed for wrist arthroscopy for a torn cartilage, a common procedure, and you’ve chosen a block.  You would receive an injection into your arm or shoulder that temporarily numbs  your arm – I’ve had one of these and know it doesn’t hurt.  After this procedure, things start to happen pretty quickly.  Frequently the nurse will put a tourniquet on the operative limb after which application of a germ killing solution and draping begin.  Your surgeon, now gowned and gloved, will say “Hi” just so you know it’s him/her, and the procedure will begin with a test of the anesthesia just to make sure you have absolutely no pain.  Very quickly, the scope will be in your wrist and the images of the inside of your joint seen on the television next to you.  Most folks are fascinated by this.

You can usually watch the surgeon’s progress in real time, while listening to what’s being done and why.  Most surgeons are very receptive to answering your questions while they work.  If any tissue is removed it is customarily discarded.

Once the operation is complete, a dressing is placed on your wrist, you get transferred to the recovery room stretcher, and are wheeled to the Post Anesthetic Care Unit where you’ll remain until the feeling returns to your arm.  It is here that any remaining pain or other issues are solved.  Often the doctor will drop by to make sure you’re OK, discuss the operative findings, and maybe even give you the photographs or a DVD of the bone or tissue that he/she operated on.  You’ll be given a post op appointment before you get dressed and are discharged.  Then, as they say in Good Will Hunting, “Let the healing begin.”

Good luck!