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Drink Responsibly: A Guide to Marathon Safety
Mark Schecker MD
Despite the growing popularity of participation in marathon events, injury rates of those participating fortunately remain very low. This is largely due to the fact that most entered in these events train properly and are well-educated as to the potential pitfalls of marathon running and walking. Most of the athletes who visit the race aid stations or the finish line medical area at the BI-LO Myrtle Beach Marathon require only minimal first aid for minor problems like bumps and bruises, strains and sprains, blisters, and nausea. It is well known that both the number of visits to medical aid stations and the severity and types of injuries seen correlate well with environmental conditions, with more casualties occurring on hotter and more humid days.
Some of the more serious injuries that occur in marathoners are directly related to fluid imbalance and an individual’s hydration status. For many years marathon participants were encouraged to drink as much fluid as possible to ward off the effects of dehydration. Dehydration occurs when athletes do not replenish lost fluids (mostly through sweating). Dehydration can hinder maximal performance and increase the likelihood of developing heat associated illness i.e. hypothermia and hyperthermia. Hyperthermia includes a continuum of problems that includes heat cramps, heat exhaustion and the more serious and potentially fatal heat stroke. The basic signs and symptoms of dehydration and heat illness range from irritability and discomfort, to weakness, dizziness, cramps, chills, nausea, vomiting and headache.
Over the past decade it has become evident that drinking too much fluid can be as serious as or even more problematic than drinking too little. Drinking excessive amounts of fluid during prolonged exercise can lead to a condition known as Exercise-Associated Hyponatremia (EAH). EAH occurs when sodium levels in the blood drop to dangerously low levels. The greatest risk of developing EAH appears to be due to drinking large volumes of fluid without adequate sodium intake during exercise lasting 4 hours or longer in which large amounts of sweat and salt is lost. If mild, EAH may cause no symptoms but as sodium levels continue to drop; a progressively worsening headache, bloating, puffiness with swelling of the hands and feet, nausea and vomiting may occur. Later stages may lead to brain swelling (cerebral edema) and if untreated severe EAH can be fatal. Unfortunately the signs and symptoms of EAH and dehydration with heat illness are very similar and it may be a challenge to distinguish one from the other.
Therefore it is also a challenge to strike the right balance between preventing dehydration and exercise-associated hyponatremia. Preventing EAH is accomplished by avoiding excess fluid retention as manifested by weight gain during or after exercise. According to experts this can be accomplished in two major ways: drinking only when thirsty or by an individual calculating their hourly sweat losses during exercise and avoiding drinking in excess of this amount. The easiest way to do this is to weigh yourself nude before you run for 1 hour in the environmental conditions and at the same pace you expect to race. Immediately following the run, towel off and reweigh yourself nude. The difference in weight is equal to your sweat rate per 1 hour. 1 kilogram of weight is equal to 1 liter of fluid (or 1 lb. = 16 fl oz.) and no more than this amount should be consumed in each hour of your race. Alternatively, this should also serve as the best way to prevent dehydration. According to the USATF (USA Track and Field) advisory, ensuring proper pre-exercise hydration requires the consumption of approximately 500 – 600 ml (17-20 fl oz) of water or sports drink 2 – 3 hours before exercise and 300 – 360 ml (10 – 12fl oz) of fluid up to 10 minutes before exercise. Urine color can also be used as a guide to hydration status and should be pale yellow like lemonade rather than dark like apple juice (dehydration) or clear like water (overhydration). Drinking electrolyte fortified sports drinks will not prevent the development of hyponatremia but are probably a better choice than water especially for those at high risk for EAH.
Risks factors for the development of EAH:Low body weight
4 or more hours exercise duration
Excessive drinking behavior
High availability of fluids
Altered kidney excretory function (including from drugs like ibuprofen, aleve or celebrex ie NSAIDS)
Extremely hot or cold environments
All marathon participants should write their pre-race weight on their race number (bib) before the start of the race. This will assist medical personnel in determining if an injured runner is experiencing the effects of dehydration or hyponatremia.
If you suspect you may be suffering from dehydration, hyponatremia or any other type of injury you should seek medical attention immediately at one of the 12 medical aid stations on the marathon course or at the finish line medical area. The Myrtle Beach Marathon medical team is composed of group of dedicated volunteers including the Emergency Medical Services of Horry County and the city of Myrtle Beach; Emergency Department personnel from Grand Strand Regional Medical Center; and a number of doctors, nurses and other paramedical providers from the community.
So remember drinking responsibly is not only for driving anymore and may be the best way of insuring a fun filled and injury free marathon day.
BEFORE THE RACE
All runners and race participants should have a medical evaluation by their personal physician before training for and competing in a marathon or relay event. This is especially important for individuals suffering from heart disease, hypertension, diabetes, epilepsy, chronic pulmonary (respiratory) disease or kidney disease. If you suffer from a chronic condition and are cleared to run by your physician, wear a Medic Alert tag and try to run with a friend. All participants should fill out the personal medical information section on the back of their race number. With proper training you will be prepared for the physical demands of the marathon. Nevertheless, it is possible you may suffer from problems like cold or heat stress or dehydration. The following information guide contains some simple ways to avoid those problems.
Listen to your body and know your limits. Do not run through pain, especially chest pain or discomfort, or breathing difficulty. If you are having difficulties continuing or cannot finish the race, ask for help from volunteers about aid stations, runner pickup vehicles or ambulance. Dozens of medical personnel volunteers will be along the course and at finish line. Dress according to weather conditions. Wear layers and remove or replace as needed. Do not stop running immediately after you cross the finish line. Continue jogging or walking slowly. Massage and stretch your muscles. Change into fresh dry clothes as soon as possible.
IMPAIRED RUNNER POLICY
We authorize our medical personnel to remove any runner deemed medically impaired from the race. We will use these criteria to determine whether you should continue. You must be able to:
Proceed in a straight path toward the finish line.
Say who you are, where you are on the course, and what
you are doing.
Look clinically fit to proceed:
(a) Good color.
(b) Reasonable runner posture.
A medical evaluation will not disqualify you from the race and you may continue if deemed medically fit.
DEHYDRATION / HYPONATREMIA
Drinking a sufficient amount of water or suitable sports drink (fluid replacement and energy drink) before and during the race is your best protection against severe dehydration on the course or at the finish. During your training you may want to practice drinking the same fluids you plan to use in the marathon. You should be appropriately hydrated when you step to the starting line. Avoid alcoholic and caffeinated beverages the day before the race that may act as diuretics. The USATF advisory recommends 500-600 ml (17-20fl oz) of water or sports drink 2 -3 hrs before exercise and 300 – 360 ml (10 – 12 fl oz) of fluid up to 10 min. before exercise. Urine color should be pale yellow like lemonade not dark like apple juice. Clear urine is a sign of overhydration from overdrinking and must be avoided. Overdrinking may also lead to severe complications due to the development of Exercise Associated Hyponatremia (EAH). EAH occurs when sodium levels in the blood drop to dangerously low levels due to excessive fluid intake during prolonged physical activity such as a slow marathon (>4hours). If untreated, EAH can be fatal. Consider drinking only when thirsty to avoid EAH. Ultimately the best way to avoid dehydration and EAH is to calculate sweat rate and weight loss during training runs. Refer to “The Right Way to Hydrate for Marathons (Q&A sheet)” provided by the AMAA and American Running Association for additional information. All participants should write their pre – race weight on the back of their race number (bib) to assist medical personnel in determining if injuries are due to dehydration or hyponatremia.
You should know what your tolerance is for heat stress and consider dropping out if conditions are above your safe level. The faster you run the higher you will push your body temperature, so slow down if it's too hot for you. You are especially at risk for heat stress if you're obese, unfit, dehydrated, unacclimatized, ill, previously heat injured, or if you've been training in cold weather. Early symptoms of heat illness include clumsiness, stumbling, excessive sweating, no sweating, chills, loss of judgment, headache, nausea, dizziness, apathy and impairment of consciousness. We will display our color-coded flag system at the start banner to let you know what the relative heat stress is. Watch for one of these signals:
1. Extreme High Risk (black flag): Above levels recommended for any competition.
2. High Risk (red flag): Runners with previous heat stress problems or cardiac disease probably should not run. All runners should run at a slower pace.
3. Moderate Risk (yellow flag): Heat stress will increase during a morning race.
4. Low Risk (green flag): Heat stress injury can still occur.
5. Hypothermia Risk (while flag): There is a risk for hypothermia.
The average temperature in Myrtle Beach during late February and early March is 60 degrees Fahrenheit. Cool, wet, windy, cloudy days (white flag at the start) put runners at a greater risk of hypothermia. The symptoms are similar to heat stress with shivering and euphoria as well. Body temperatures may fall after the finish when blood energy supply is low, the temperature regulation system is impaired (often by dehydration), and you are unable to generate muscle heat from exertion. Seek shelter and dry clothing quickly. Drink fluids immediately.
Skin in high friction areas (armpits, nipples, groin and feet) should be well lubricated. Petroleum jelly works well. Wear shoes that are broken in. Thin socks may decrease foot friction. Polypropylene liners help keep your feet dry. After the race, clean any blisters with alcohol and drain them from the side with the skin cover left intact. If you are unsure of this, seek medical attention and certainly seek medical care if signs of infection appear.
If you are ill on race day or a few days prior to the race, your risk of injury increases and you should consider withdrawing. Remember, chest pain / discomfort, breathing difficulties or fluid imbalance should not be ignored, and if they develop, you should seek medical assistance immediately. Your health is too important. There will always be another race. Medical personnel will be available along the marathon course to provide first aid. Participants with more serious needs will be transported to or referred to appropriate facilities. Once discharged, participants who require first aid or more extensive medical assistance are advised to follow up with their personal physician.
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