Hawaii Ironman- a sports medicine experiment like no other
by Julia Keith

The Hawaii Ironman Triathlon needs little introduction . It is an awe inspiring event that becomes somewhat infectious to those who get involved, whether they’re a spectator, athlete
or part of the volunteer medical team.

For the uninitiated the race involves a 3.8km swim, 180km on a cycle and a 42.2 km run.

But that’s the easy part. Athletes also need to contend with the harsh environmental elements that make the Hawaii Ironman the unique event it is.

Let me explain

The 3.8km ocean swim
The swim occurs in Kamakahona Bay – where 1500 participants start together. Apart from the dangers of being kicked, punched and scratched by fellow athletes, the unsavoury issue of swallowing sea water is a common problem . Vomiting is often the result. The ocean swells can also cause sea sickness.

The 180 km cycle
The cycle course delivers a stretch of road called the Queen Kaahumanu Highway which travels through 100 year old lava fields. It is here that the winds can be a huge test of character. They can range between 40-72 km an hour with gusts up to 96km an hour. Last year’s race experienced the strongest ever winds in the history of the event, where participants were literally blown off their bikes. One competitor even suggested he had to use his windsurfing skills to anticipate the gusts of wind and cycle accordingly.

Fortunately there are moments when the competitors get to savour the tail winds. But no time is wasted as they try to remain aerodynamic and refuel with food and drink at the same time.

The 42.2km marathon
The run occurs during the hottest part of the day and there is no escaping the sun: it beats down on the competitors for the whole 42.2km. Athletes talk about spending the entire marathon just trying to cool themselves. It is an impossible task in the sometimes 38-40 degree heat. Competitors use every aid station to refuel and to pour water on themselves and put ice in their caps. It is an uncomfortable state that leads to soggy shoes and, later, blisters. Their legs feel like lead.

The participant
The average time it takes participants (who are aged between 13 and 84) to complete the event is 11.5 hours. The elite finish in 8-9 hours. The rest have up to 17 hours or until midnight to finish .

All competitors qualify to be eligible for the privilege to race in Hawaii – the World Ironman Championship.

The Environment
Mix with this the heat which rises to 40 degrees in the lava fields, humidity 90% and blustering winds up to 96km /per hour and you get a sports medicine experiment like no other. And it’s an experiment that Ironman Medical Director Dr Robert Laird knows only too well.

The Medical Coverage
For the past 21 years the 57-year old Laird, whose real job is in Pediatrics and Adolescent Medicine Kaailua Kona, has been volunteering as part of the medical team for the Ironman. Ironically, he puts in longer hours as Medical Director than if he was to do the race himself -- a point he proved in 1988 when he did his own personal experiment and finished the Ironman in 12 hours 41 minutes. By comparison, his shift during the race is up to 23 hours long – starting at 5am and finishing around 3am.

Luckily he shares his work load with around 65 doctors and 120 nurses and paramedics from all over the world who donate their time to staff two medical facilities, seven radio-equipped emergency vans and an ambulance. Apart from this, the Kona community contributes nearly its entire medical and massage community to the triathletes on race day.

The Medical Treatment
So what exactly are the most common medical issues that occur during the race ?

It’s no surprise that Dr Laird and his staff end up treating many cases of dehydration, heat illness and hyponatremia (low sodium in the blood). These ailments usually crop up in the later stages of the run or after the competitors finish.

As studies have shown, one third of triathletes are excessively disciplined, competitive, preoccupied with perfectionism and have high standards of performance, mental and interpersonal control, and orderliness. In other words they are stubborn and will do what ever it takes to cross the finish line.

Dr John Dormois, a physician who volunteered to assist in the medical tent in 1997, was surprised to see so many finish the race.

“An amazing 97% finished the race (out of 1500). There were very few instances of failure to finish due to medical reasons.” He said that those who were taken to the medical tent after the race suffered from symptoms compatible with exhaustion. “This was manifest in a variety of ways but particularly by feelings of lightheadedness, dizziness and weakness. Intense muscular cramping of the extremities was noted in a few instances.”

Approximately 20-30 percent of all participants need medical attention at some stage through out the day. Naturally, the less serious complaints of pain in a joint, severe blisters and muscular pain are common. But those who do end up in a really bad way, Dr Laird says, are those who continue despite incredible obstacles.

“ Some push through with bloating, severe cramps, vomiting and diarrhea. Some end up having surgery to remove portions of the intestines. It’s rare – but it happens.”

One example was Australian Ironman Chris Legh who collapsed with only 100metres to go in the 1997 event. Dr Laird assessed him and decided he could not continue, despite his efforts to crawl. It was a dramatic, eerie finish to his race. He was stretchered over the finish line and subsequently disqualified.

His condition was caused by a combination of issues including his loss of Gu flasks during the race which made up 1500 calories, and then his body rejecting any liquids and food and finally severe diarrhea and vomiting. He then spent three hours in the medical tent receiving much needed IV fluids. The following day, he suffered severe stomach pains and a high fever, resulting in emergency surgery where he underwent a right hemicolectomy and an appendicectomy, losing approximately 15cm from his large intestines and his appendix

Amazingly, the surgeons suggested there would be no long terms effects and Chris has in fact gone on to post successful Ironmen race results.

Two other elite triathletes succumbed to similar collapses only metres from the finish line, but managed to crawl over it.

Wendy Ingraham and Sian Welch were both within 45 metres of the finish line when they simultaneously suffered severe cramps and wound up racing each the only way they could…by crawling.

“It was like someone took a baseball bat and whacked my legs," said 34-year-old Ingraham .

Ingraham, who uses salt tablets during the race, said she lost them and as a result started cramping during the run.

Welch on the other hand found herself vomiting during the bike leg. "I had no electrolytes and was only drinking Coke and water."

But despite their dramatic finish both women continued in their triathlon careers with no long term medical effects.

Dr Laird recalls an incident in the early years of the triathlon when Julie Anne White of Canada finished 2nd to the infamous Paula Newby-Fraser despite feeling progressively worse as the run went on.

“Julie Anne’s stomach shut down somewhere in the run – in extreme heat and exhaustion the body can shut down blood to the intestinal tract. What happened to her was incredibly painful, but she had such a strong will she kept going. Afterward they had to operate on her and remove part of her intestine. She recovered though and finish the year later in the top five.”

But the elite are not the only ones who suffer from the extreme conditions of Hawaii. In the 2000 Ironman Sister Madonna, at the age of 70, had a bad bike accident caused by gale force winds. She suffered multiple abrasions and bruises, a wrenched left hip, a broken clavicle and 20 stitches to her face. Such is the iron will of these competitors, she was back again the following year and finished in 16 hours 49 minutes.

Dr Doug Hiller , a Honolulu orthopaedist said, “we pray every year that no one will die during the event. No one has. But because everyone who gets here is so fit, the people with physical flaws have been pretty well siphoned out.”

Some may suggest that God was on Sister Madonna’s side that year. Certainly, it seems a miracle that no competitor has died in the history of the event.

However the Ironman Sports Medicine Planning Committee could probably take some of the credit for this. Part of its job is to keep track of the athletes’ medical care following the race. It also examines the medical records of the athletes sent to the Emergency Room at the Kona Hospital, together with other medical records from endurance events. The goal of the committee is to learn from the treatment of athletes in order to educate physicians on optimal management strategies for collapsed athletes. The information is also used to develop preventative and treatment strategies.

Most of this information is then presented as part of the Ironman symposium held each year before the race.

Dr Laird says the unique environment has enabled the medical team to learn about the long term effects of triathlon. “We’re in a position now to gather information on the long term effects of the sport. We want to find out what happens after the race.”

So far he and his invited team of primary care physicians from the fields of internal medicine, family practice, pediatrics, emergency medicine, physical rehabilitative medicine, physical therapists, athletics trainers, physician assistants, nurses, exercise scientists and other health care providers have been able to study such issues as osteoporosis, hyponatremia, thermal regulation, fluid and electrolytes, gastrointestinal function and the psychology of triathletes.

Dr Laird believes that the success of the sports medicine coverage is due to the medical volunteers. “They come back year after year for the privilege of losing income, rest and time with family to assure that the Ironman competitors receive the best event medical care available on the planet.”

He also praises the event organisers who have given him “pretty much anything I ask for because the safety and well being of the athlete has always been at the tip of their priority list”.

Such has been his own huge contribution to the Ironman that he was inducted into the Ironman Hall of Fame last year.

His only regret so far in his 21-year involvement in the Ironman has been with his own race effort. “If I would just have eaten a little less chocolate and run a little more during training….”

But who ever said sports medicine practitioners practised what they researched ?

Each year prior to the Hawaii Ironman the program planning committee mounts a conference to provide a forum to exchange new information regarding the benefits and effects of exercise on athletes. Each year they review the essentials of medical coverage at endurance events and also provide an opportunity for physicians and nurses to work in the Ironman Medical Tent on race day. For those interested log onto www.ironmanlive.com.

Julia Keith is Executive Officer of the ACT Branch of the SMA

Breakouts
There were 1500 competitors in the 2002 Hawaii Iironman, including about 95 Australians. Competitors consumed enough bananas to feed two monkeys for a year at the Honolulu Zoo.
The combined fluid replacement drink, cola, soup, water and ice consumed could fill three Olympic-sized swimming pools.

When the race originated in 1978, athletes were weighed during the event to ensure they had not lost too much fluid. This does not occur today – it would be impossible with 1500 athletes compared to the 15 who participated then.

The equivalent physical toll on the Hawaii Ironman, according to Dr Laird, is like doing 3 marathons in a row. He suggests that the average person competing over 12 hours will burn at least 6000 calories and sweat about four to five gallons of fluids.

One study has shown that men and women aged 40 to 76 in the 1999 Hawaii Ironman showed equal amounts of bone density in their lower spines and upper thigh bones, where osteoporosis is often seen. It suggested that women over 40 do not have less bone density than men and that triathlon training can in fact strengthen the skeleton.