Thursday, July 24, 2014

How to Break Your Age Group Record

Please note: my two sons and I are heading to California's Sequoia National Park for a week of backpacking and climbing Mt. Whitney.  I'll have no internet access, or electricity for that matter, for about ten days.  See you in early August.
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Call me a relic call me what you will
Say I'm old fashioned, say I'm over the hill.
Today's music ain't got the same soul
I like that old time rock and roll.
                                                                                                  Bob Seger



Maybe not everything benefits from getting older
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On October 11th, the age group record for the Hawaii Ironman Course in the 65-69 year old age group was 11:19:07 set in 2011.  The next day, an athlete named William Wren decided to put in a spectacular performance and dropped it to 10:44:31.  That's a 30 minute drop in one year folks!  And against the hardest competition in the world.  He managed a 1:04 swim, 5:29 bike, and 4:01 run against 35 others in his age group on race day.

What's Wren's secret?  Well one of them is, shhh don't tell anyone, he aged up!  Yep, into a new age bracket where everyone else was his age or older.  None of those 64 year old whipper snappers to race against for example.

I've written about age group record holders before and where some of them plan for a year, maybe even two years, for a day like William Wrens.  We can learn from him.  If you have a specific race or individual goal, like toeing the line on famed Alii Drive on the Big Island as part of the World Championship field, then perhaps you can pick a qualification race one year, maybe even two years, in advance to give it your best shot at qualifying.  It would be the year you turn 45, or 65 like Wren for example.  (Just to be on the safe side, you wouldn't put all your eggs in one basket, like having only a single shot at the Olympics.  There might be a conflict such as a wedding or other family issue which effectively eliminates your prime choice so you'd simply move to race "B".)

Your second step would be to drastically increase your knowledge base about the available events, comparable difficulties, etc. including checking out author Ray Britt of runtri.com.  He has two very easy to read books called Racing Ironman and Qualifying for Kona: The Road to Ironman Triathlon World championship.  Your goal may not be to qualify for Kona but Britt has a great deal of usable stats and advice so I own a copy of both.

Lastly, if you're going to put your all into this adventure, is there something else that you've perhaps dreamed about that will put you over the top?  Do you have a race limiter that you could devote a little more time or energy to?  Perhaps it could be professional swim lessons or a treadmill eval of your running stride that can keep you injury free while fine tuning your body for this effort.  Would having a coach help?  Well, if you turn to Ironman.com and their FAQ section, the answer you get is "You can take two routes: either work with a coach or do the research yourself. You’ll find plenty of books and online materials about triathlons, but we find that working with a personal coach is important for about 75 percent of IRONMAN athletes." 

I was in charge of bike inspection in Hawaii this year and I watched folks from Training Peaks ask every athlete who checked in and racked his/her bike the afternoon before the race, "Would you mind taking a one question survey?"  The athlete didn't even have to slow down to answer.  The question was, "Do you have a coach?" Over half of them said yes.

I would be remiss if I left out your support crew, your family, because if you're really going to do this it becomes a family effort like it or not.  Perhaps you offer a significant vacation - no not to Kona where you'll be as distracted as can be - but to some place of family significance where swim, bike and run are not on the agenda.  Well, they might be if you and the family were doing them together.  At their pace.

We may not all be William Wren's, whom I've been told is a really nice guy, but if we're smart enough and patient enough, we might just be able to reach that triathlon goal a year or two from now when we age up.  If Wren can, you can.


Care to be the first to rack your bike at your goal event?



Monday, July 21, 2014

Business Traveler? Here's How To Continue Your Workouts Away From Home



Author's note: I've received two notes that some of you are having trouble reading this blog on occasion.  One reader today described it as, "The white background just fades away and it's black letters over the swimmers."

If you have any difficulties whatsoever, might I ask you to shoot me a quick email  at jpostmd@trainingbible.com so I can fix the problem?  Thanks very much!

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Coming to a bike shop near you?


I've already been out of town twice this month teaching courses to Primary Care Physicians.  While seeing new places and meeting new people is always fun, keeping up with working out can some times be a challenge.  This can be especially true in a foreign country.  But with a little prior planning, and the Internet, you can keep a reasonable facsimile of training going.
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Swimming - It couldn't be easier.  For starters, you only need one stop: www.usms.org/placswim . As an example, I have to go to Phoenix in November to teach a course to the American Association of Family Physicians.  I went to this site, found four groups to swim with and about 20 separate pools.  I'm drowning in choices here.  (Sorry, couldn't resist.)  So before I go I'll call ahead, ask about hours, local customs, coached work outs if I'm in the mood and I'm all set. And I always bring spare goggles.

We were in Iceland in May and simply spending time with Google, I found a place in Reykjavik that had not one but two geothermally heated 50 meter pools...and I'm a swimmer!  To quote John Sebastian at Woodstock, "I'm in heaven, man."

Running - I doubt that you need any help here.  That said, it might be nice to know where the best places to run are at your destination city that the nonexercising night clerk of your hotel may be unaware of.  A couple times I've contacted the local Road Runners Club of America folks and been given good advice.  Or stopping in a nearby running specialty shop where most of the folks who work there are runners works great.  If you were to come to Charlottesville, and stopped in at Ragged Mountain Running Shoes, not only would everyone there be able to tell you where to run, likely as not, they'd be able to give you a paper map, not only of the route but how to get there!  I doubt this experience is limited to Virginia.

Cycling - This can be a little more of a challenge. As every reader is aware, bike transport has become prohibitively expensive saved for that one "A" race per year upon which your whole season is based.  And to tell you the truth, it can be a real nuisance. I've read that some can get their bike into a hockey equipment bag and avoid the airline fees where others have folding bikes, or ones that come apart, for just such use.  They can be in several price ranges as seen here https://www.youtube.com/watch?v=OqrTh4FhbKg .  Spinervals videos by Coach Troy Jacobson are designed for indoor use and you might check them out also.  

Some bike shops like BikeWorks in Kona have a whole stable of quality rentals (call early because they go fast.)  Your own bike shorts and jersey are useful.  Although you can use theirs, if you bring your own pedals and shoes, and maybe even saddle and bike lock, they'll do the rest.  This may be overkill but I also bring my Road ID and under saddle emergency bag as I'm just as likely to have need of bike repair or first aid there as at home. 

For my money,Slowtwitch had a work out credited to Lance Armstrong which I copied years ago and would encourage you to do the same.  It's free, can be done on just about any hotel exercise bike, and is infinitely adjustable by you to keep it interesting.  I've done this, or something like it, countless times and always feel that my log book will be pleased when I get back home.

Lance's Traveler's Bike Work Out For Stationary Bike -  Print out and stick in your suitcase

Start with an                   8 - 10 minute Warm Up
then: Fast pedal            1 Minute
         Recovery              30 Seconds
         Fast pedal            1 Minute
         Recovery              30 Seconds
         Hard effort            2 minutes - 7 on a 1-10 scale
         Harder (9 effort)   1 minute
         Hard effort            2 minutes
         Harder                  1 minute
         Hard effort            2 minutes
         Harder                  1 minute
         Easy Spin            6 minutes
         Hard effort            2 minutes 
         Harder (9 effort)   1 minute
         Hard effort            2 minutes
         Harder                  1 minute
         Hard effort            2 minutes
         Harder                  1 minute     
         Cool down         10 minutes

It's 47 minutes and if you're type A (say it isn't so) and want an even 60 minutes, adjust as you please.


Happy Traveling!


Thursday, July 17, 2014

Seen Blood in Your Urine? Dark Urine? Read on.


Author's note: I've received two notes that some of you are having trouble reading this blog on occasion.  One reader today described it as, "The white background just fades away and it's black letters over the swimmers."

If you have any difficulties whatsoever, might I ask you to shoot me a quick email  at jpostmd@trainingbible.com so I can fix the problem?  Thanks very much!
________________________________


Any fellow age groupers just nip you at the line? Now's the time to prepare for those late summer and fall races to walk home with the victory.  When was the last time you practiced your transitions? Really practiced by setting up a transition area at your house or local park and going through this discipline over and over?  A surprisingly small number of triathletes do and it's such a easy place to gain time, from seconds to even minutes in some cases. 

One of the highlights in Kona, the Underpants Run. This is the silly oath.




Bloody Urine 

After a pleasant work out, and a trip to the rest room, you look down and  see blood in the toilet: now what?



 Ever looked into the commode after your long run, and instead of
the usual concentrated deep yellow urine, you
see blood?
  Or maybe just extremely dark urine?  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 25, 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 and running related issues.  One day, out of the blue, with no particular trauma or warning, he
started with a very slight pinkish tinge to his urine after his longest runs
but over time 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, a type of 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 running 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 at 24, with a head full of steam, he's his own man.  And,
like many other things we see happen to this 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.  Or, an  equally common scenario is that it resolves for the most part but every once in a while, again after long runs only, the urine is said to be "a little rusty."  This puts runner and family at ease, however, understanding that it's not cancer or something more serious.  As they say in Minnesota, "Good deal!
"

And, some months later, the problem, like so many in our athletic careers, spontaneously resolved!

Tuesday, July 8, 2014

Big Incision: When You Are Considering Going Under the Knife


Even Doctors Have Surgery

A true story of being on the other side.



The cardiac surgery team of fellows and residents was rounding on me the evening before my heart operation, and I wasn’t comfortable being “rounded on.” Six months had passed since my near-syncopal episode during an emergency department shift on the cusp of my 41st birthday; 6 months of imperfect practice as a patient. Pneumonia, rapid atrial fibrillation, and a leaky mitral valve—all a surprise to someone who thought himself too busy to be sick.

 
“It must be hard being on the other side,” a surgical resident said. 
I was learning that this wasn’t a question but more of a shamanistic incantation by fellow doctors eager to ward themselves against my fate. No cardiac risk factors, exercised regularly, flossed enough. Yet, here I was, wilting before puzzled faces straining to fit my illness into an unaccommodating cautionary tale.


The team left, and a tall, casually dressed woman—the chaplain—knocked on my door. She knew that I was a physician, and that I was aware of my diagnosis and the impending surgery.
“Are you scared?” she asked.
My wife sat wearily at my bedside. My son, 5 years old at the time, was back in Providence. “No,” I lied.


She smiled stiffly. “This experience will change the way you relate with patients, no?”
“I don’t believe illness must be accompanied by great meaning,” I told her. “Sometimes a crummy heart valve is a crummy heart valve.” Genuine concern tightened her face.
My wife politely interjected. “It’s been a long day.”
The chaplain slipped her card upon the bedside stand. “Patients often decide to talk after surgery.”
“Thanks. I’ll be OK.”
“I’ll ask the rabbi to visit?” I remembered the Jewish high holidays when I was younger. The spectacle, the feverish sermons, the sparkling, low-cut dresses.
“If I need an ear,” I said, struck by the chaplain’s sincerity, “you’ll be my first choice.”
I didn’t intend to be difficult, but being inside serious illness is a different experience than talking about it. The ill person’s mind earns its own logic, divines its own purpose. That didn’t include being buttoned inside a sentimental parable, or hijacked to drive a cautionary tale. I was a white coat in a hospital gown, and I simply wanted permission to be sick.


Serious illness had impacted my doctoring but not in ways the chaplain might find praiseworthy. The petty humiliations of life as a patient in the emergency department were acutely shameful—the cruel stretchers, the ugly gowns, the theater of privacy afforded by curtains pretending to be walls. As patients and families nervously awaited more information, I was inside their worry. For those unfortunate patients without health insurance, I fought harder to arrange services in a broken health care system.


But this heightened empathy and compassion were balanced by intolerance for patients seeking work notes for minor ailments and a gnawing insensitivity toward rude patients and families who lacked patience or understanding. Pity the drug seekers or patients who treated their bodies like chemistry sets.


Traveling further into illness, I discovered fewer recognizable roads for my type of journey. Months after first becoming ill—and countless failed attempts at electrical cardioversion—it became obvious that my leaky mitral valve needed repair or replacement. Suddenly, I required a cardiac surgeon. Friends and colleagues at a prestigious medical center immediately recommended Dr. A, a humanist with excellent hands. My cardiologist insisted upon a Famous Heart Surgeon (FHS) at the same institution. One of my closest friends, a cardiac surgeon at a distant medical center, counseled me about the FHS and his accolades and skills and notorious personality. He shared stories from fellows who endured the FHS’s wrath as a rite of passage.

 
“That shouldn’t concern you,” my buddy said. “You’ll be under anesthesia.”
My wife and I arranged to meet these two giants on the same day. That morning, we were escorted into Dr. A’s world—office of dark wood and soft chairs, silk tie precisely knotted, white coat pressed and devoid of the ink and coffee stains that marked mine. His carefully chosen words were crafted into lucid paragraphs, tailored to fit my ears and those of my nonmedical wife. His physical examination matched that of any uber-internist. I wanted him as my surgeon, friend, mentor, and life coach.


Afterward, my wife and I lunched ravenously in the hospital cafeteria. We had Dr. A in our back pocket. Our consultation with the FHS awaited us, but it didn’t matter.
He was donned in scrubs, a sport jacket, and expensive-looking leather shoes. He greeted us with perfunctory handshakes, barely acknowledging my wife. He raised my thick medical chart as if it explained everything and dropped it on his desk. “You need an operation. Questions?”


Was he kidding? He wasn’t kidding. I heard my wife whimpering for Dr. A.
I tried to penetrate the FHS’s brazen exterior, find a pulse behind the steely blue eyes that discounted my questions on complications from bypass pump and the success rate of valve repairs. I asked about his work doing mitral valve surgery with a small chest wall incision instead of the median sternotomy. The possibility of less pain and faster recovery appealed to me. He killed that option. 
“You need a Maze, too,” he said. “Atrial fib and the heart valve. You’re looking at a big incision.”
I was transported back to the intimidating surgeons at medical school and during my residency. Only I was a fellow attending now. I was a patient.


“We had a consultation with Dr. A this morning,” I said.
He nodded respectfully, then gave me a look that was scalpel sharp. “Remember this,” he said. “Your problem is nothing special. I did two of you this morning.”


We left his office feeling relieved and disoriented, as if we’d just stepped off a gravity-defying amusement ride. My wife and I slowly negotiated the corridor. We stopped, faced each other. “He’s our guy,” we declared.


The decision defied rational explanation. We had completely, and without reservation, invested our confidence in the empathic and talented Dr. A just a few hours before. But did I really need empathy, or someone to hold my hand? I reconsidered Dr. A’s responsible and cautious detailing of the surgery, his honest admission that the valve might be too damaged for repair. That meant replacement, and possibly lifelong anticoagulation. The FHS didn’t express such gravity. He seemed bored with my heart problem, even annoyed by it. Did he routinely inform patients that their problems weren’t special? Or was he savvy to the workings of the physician-patient’s mind, and his brusqueness functioned as a communication strategy?


Each time I tell this story, I’m greeted with genuine shock from students and colleagues who can’t believe I passed over the ideal embodiment of a surgeon in favor of someone who couldn’t be summed up as easily. From the moment I set eyes on the FHS, this complicated character, I knew what type of surgeon I needed—a distinguished, hard-driving, and unapologetic adversary.
How could I explain this reasoning to the big-hearted hospital chaplain?


Long after the chaplain had left and my wife went home to our son, there was a soft tap on my door. A medical student in a short white coat asked about a history and physical examination. Sleep and worry tugged on my sleeve, but I waved him in.
“Does it feel strange?” he asked when we finished, nodding to my place on the bed. “Are you scared?”
“A little,” I said. “And a lot.”
Somehow, his lack of responsibility for me and his innocent and distressed look when asking these questions upended my defenses. Fear hit me hard. I sat up higher, as straight as I could. He licked his lips. Should I tell him what I’d told the chaplain?

“Be wary of scripts that make patients feel miscast in a movie of their own illness,” I said. The student’s gaze didn’t waver. “You did a good job. Doctors can be complicated patients.”

The morning of my surgery, after a nurse’s aide nearly broke an electric razor shaving my chest hair, I lay under a sheet in preop, more naked than I’d ever thought possible. The FHS entered. We shook hands for the first time since our meeting several months before. He appeared well-rested, freshly showered. He kept tapping my chart as if he couldn’t wait to start. How can I describe my emotions? My fear was swept up inside his energy, his confidence, his focus. So much was happening that resisted making any sense. A sedative started swimming through the IV. I didn’t feel calm. My body asserted itself, assumed a weightless density and cocky buzz, and I welcomed its invitation to retreat into it.
“See you inside,” the FHS said. 
Those words played with me. Did he mean inside the operating room, or inside my chest? He was about to turn away, but stopped. “What are we doing again?”
Was he serious?
“Mitral valve? Maze?”
“That’s right.” He delicately drew a straight line with his index finger over my chest. “Big incision,” he said, and winked.


Jay Baruch, MD
Alpert Medical School at Brown University; Providence, RI 02903


If you enjoyed reading this piece, this author has also written Fourteen Stories: Doctors, Patients, and Other Strangers (Kent State University Press, 2007)