Medical Update

LONG POST - Update on Randy condition from a medical perspective from the Team MD.

---------------------------------------------------------------------------

We survived the desert of day 2 with temps up to 114⁰. Randy required continuous cooling w/ice to make it across. We used “insulated” Water bottles, 1 with iced water to wet himself with. The second bottle was for Randy’s drink. The relevant temperature management strategy was to change bottles every 15 mins with one ice cold, just half full. Another component was a plastic bag lined ice sock around his neck, tucked under his jersey, and changed every 30.

Going into that day from a medical perspective, Randy still did not have sufficient internal sodium and magnesium stores to allow good endurance in that oven going to Congress, CA. We even dissolved 1 Lava Salt tab in each of multiple doses of ice cold chicken broth which he drank like it was cold beer during the ride the day before, and with all of the different methods of administration, he received 9000 mg of various sodium salts, and 6.5 gms of magnesium sulfate in less than 24 hours. The use of white sun shield arm covers, kept continuously wet along with his head sweat and upper jersey in the <15% relative humidity allowed sufficient evaporative heat loss due to rapid evaporation to allow him to ride throughout the day. Whew, I don’t know whether he or the vehicle air conditioners were working harder. A few doses of SPF 70 sun screen got the whole Team through with no serious sunburn.

As we rode thru the night of day 1, and thru day two, Randy’s fluid status improved, and the impressive net weight losses (up to ½ lb per hour riding) we observed during the first 24 hrs begin to abate. His ability to tolerate street food improved. All readers should note that when a rider is going hard in 110⁰F+ temps, they do not tolerate ANYTHING solid, chocolate, or really sweet tasting, and are generally limited to about 200-250 kcal per hour intake. Without this nutrition and enough high salt fluids, they will eventually just fall off their bike. This finding is consistent with experience in much shorter events such as a hot IM race or International Long Distance Triathlon Championship event.

My opinion about the physiology is that under such extreme stress such as the Desert, the stomach requires VERY simple things to allow continued function. Isosmolar fluid intake only, simple sugars, nil fat, no protein, just amino acids.

The issue of the next several days: THE ARSE. Almost all distance riders experience at least some perineal discomfort on longer, and especially multiday rides. RAAM lore is replete with tales of unimaginable misery due to perineal breakdown, and resultant almost unbearable discomfort. Randy had previously experienced prolonged perineal folliculitis in the anterior perineal region on more than one occasion. This responded very nicely to the appropriate antibiotic ointment in March. Prior to this he had tried several therapies, had recurrence with each return to increased saddle time, and was at least very frustrated. His posterior region pre-race was pristine, but by about 14 hrs or so in the saddle, the areas over his sit (ischial) bones on both sides were red and getting sore. We increased lube and began increasing the frequency of changes to fresh cycling shorts, and applying hi Vit E cream to the area in addition to his chamois cream. By 40 hrs in the saddle, we clearly were not winning the battle, but skin breakdown was not imminent. As his weight with each stop was stabilizing, indicating at least temporary continued resolution of our previous fluid and electrolyte battle, a worsening situation in the basement could soon become Randy’s major limiting medical problem. Not that the usual severe sleep deprivation for all concerned is not really a problem, just the normal environment in the game of ultra-endurance multiday cycling.

After my 16 hr shift, I tried to get my sleep break started while remaining completely confused as to why the location and nature of Randy’s perineal misery was so completely different than his previous problem……At about 0200 RAAM Race Time, I bolted straight up awake with an “Ah Hah” Moment, only to crack my head on the overhead of our RV. The reason was that Randy lowered the saddle nose weeks ago due to the painful pressure on his anterior perineum due to the chronic infection there…AND it was still down!!!! Damn, I must be getting old! The increased pressure posteriorly simply must be the underlying cause of why the location of the trouble had moved so far in less than 6 weeks. One part of the solution must be to level the saddle…Done at TS 13, saddle back to level, and that should reduce pressure on the sore areas. The saddle sore saga continues, more to follow.