Wednesday, December 9, 2015

When Ridiculous Just Isn't Enough

“An adventure is misery and discomfort, relived in the safety of reminiscence.”--Marco Polo 

This past year, I knocked out a 50 Mile Run, Rim to Rim to Rim of the Grand Canyon, and Ironman Arizona once again.  At one point, all of these things seemed impossible.  But with them solidly in the rear view mirror, I feel like it's time to up the ante.  Not to take anything away from the these accomplishments, but I'm ready to try things that seem really and seriously impossible--a 100 mile run and a Double Iron distance race (281.2 miles).

I think that race distances are like kids--you just want to have one more, until that last one is just too much.  And I'm not there yet.

Yes, the lure of combining things that I really love--swimming, biking running--with something that I really hate--being awake for 20-30 continuous hours--is just too much for me to leave it alone.  Plus, I'm going to be 49 this year, at the "bottom" of the 45-49 age group.  Not that Kona qualification for the 50-54 age group was any slower--It just wasn't.

So I'm signed up for the Born to Run 100 miler in California, just 2 days after the big 4-9.  Then in October, the Virginia Double Anvil.  And just because that's what this year is all about, I will also be doing the Wilderman 140.6 offroad triathlon in between.  And IMAZ again 6 weeks later, only without all those pesky expectations of being in prime condition to make a run at Kona.

I'll probably find a few more reasonable things to do.  As always, Karen and I will have our annual Valentine's Day Outing, the Mt. Taylor Winter Quad in Grants, NM.

So, it looks like next year will also be full to overflowing with awesomeness.  See you on the trail, on the bike path, or in the pool.

Friday, October 9, 2015

Atrial Bleeping Fibrillation, Part III: P-Waves From Heaven

On Monday night, I went for a quick, easy run while the kids were at Karate.  I was definitely in atrial fibrillation when I started.  So I started off with what appeared to be the "new normal," a heart rate limited slog at roughly 50 miler pace.  But I just kept going, pushing a little harder from time to time to see how it felt.  By the last hill, I felt pretty good, but didn't think anything of it, even afterwards.

But as I would discover later, my heart had snapped back into regular rhythm.

With a quick study of the .gpx file from the run on Trainingpeaks, I think I can guess to within a minute when I converted back to Normal Sinus Rhythm by looking at how efficiently I run.  The metric of "Efficiency Factor" (EF) is computed by dividing running speed (normalized for grade) in yards per minute by average heart rate.  Note the overall EF of 1.43 in the first frame:

Frame 2 highlights a roughly 2 minute segment 12-13 minutes into the run, with EF of 1.28.  This is typical of what I've seen during my week of Afib, and is far from the EF of 1.5-1.6 that I usually see.  A 10-20% loss of high end cardiac output, and therefore efficiency, is what is expected for Afib.  Not a literal killer, but certainly a killer of any chance of qualifying for the Ironman World Championships, which has been a perennial goal of mine for the last 3 years. 

And in the final frame, the EF is suddenly back to normal values:

 Later that evening, I checked my pulse, expecting it to be irregularly irregular again.  But it was surprisingly constant.  I didn't want to believe it, but it remaines so five minutes later.   And in the morning, I hooked myself up to a monitor at work:

GE.  We bring good things to life.  Like NSR.

P-waves! Glorious P-waves! And they've remained there since.  With the exception of a couple of skipped beats that scared the holy hell out of me, they've remained.

The next morning, I felt as if someone had slipped me an (extra) quad espresso.  I was walking on air, and my swim felt supercharged.

Unfortunately, speaking of espresso, I'm still going to pursue the prudent course and keep ratcheting down caffeine.  I'm grieving.  I love me some stimulating beverage.  It's basically my only remaining vice.

The leading theory for how it happened to me remains the altitude tent, or at the very least, the simulated height to which I pushed it and how soon I did it (increasing 500-1,000 "feet"/week, sleeping nightly (and often poorly) at 10,000 "feet."  This article (Thanks to Ted Rasoumoff) would suggest that pulmonary artery pressures go up substantially, even in asymptomatic residents of high altitude.  Between this and three 20 hour weeks of training, plus work, plus family time and duties...I know, but there are just so many awesome things in my life that it's easy to want to do it all...there was just too much stress and not enough recovery going on.  But I'll say it one last time: As someone who grew up at 7300 feet, I would've thought this was going to be pure gravy.

I had felt some sense of strain and for lack of a better word, bogginess, in my chest for the week or two before recognizing the irregular heartbeats and Afib, and it was starting to feel a little difficult and uncomfortable to lay flat and sleep in the tent.  I wrote some of this off to the small enclosure itself (it's just a hood that covers the head of the bed, and can be mildly uncomfortable), but clearly there was more to it than that.  It makes mechanistic sense that increased right-sided heart pressures led to stretching of the right atrium and the corresponding cardiac conduction pathway, which is how you get arrhythmias like atrial fibrillation.  It also follows that quitting the tent would allow pulmonary pressures, then right-sided heart pressures, to decrease.  Then the atrial conduction pathways would shrink back to normal length (as this was not yet permanent cardiac remodeling).  Then the aberrant conduction would go away when the normal course of electrical impulses through the atrium overrode it and took back over.

Responses of this sort to an altitude tent have not been reported with any great frequency.  But obviously, that's irrelevant to me.  The altitude tent experiment is certainly over.  Look for it on Ebay.

Since I'm feeling like a cool million, I'm going to slowly and cautiously start ramping up the mileage again in preparation for Ironman Arizona.  Assuming my working hypothesis is right, this shouldn't be a problem.  But I guess we'll see.  Say a prayer to Our Lady of Regular Heartbeats for me.


Monday, October 5, 2015

Atrial Bleeping Fibrillation, Part II--Gathering Info and Planning

Larry was most helpful.  No surprise there!!

Main points:
1) Afib likely to be recurrent.  (Again, I actually think I might have had it back in '99 after I ran my first marathon.  I seem to recall "funny heartbeats" for awhile after it, but they went away.)
2) Cardioversion and antiarrhythmic drugs are hit-or-miss.  They may or may not keep me in normal sinus rhythm (NSR).  In triathlon terms, NSR means that the atria squeeze in a coordinated manner before the ventricles, and I get to keep that 10-20% of top-end cardiac output, which is pretty important in a race).
3) As I suspected, anticoagulation (coumadin) is not necessary for me personally to decrease stroke risk.  With the exception of Afib, I just don't have any risk factors.  Asprin every day is enough.  Endurance athletes are just not likely to have the risk factors to justify coumadin (big gun blood thinner).  Plus, a hard bike crash on coumadin would not be good.
4) Catheter ablation is more reliable, but not 100% either.  This will likely be the solution if it recurs.
5) I will not just drop dead from afib (I was 99.94572% sure this was the case; it was my wife's question).
6) Having used an altitude tent for the last several weeks was a likely contributor of cardiac stress, but not a known cause of Afib.
7) Dudes and chicks over 40 have a 1 in 4 lifetime risk of afib.

What to make of it all? I'm almost undoubtedly still doing IMAZ.  I may not have the day I want, but that's just a little more out of my hands than it was a couple weeks ago.  We'll see what happens.  Still gonna be an endurance geek, still gonna give KQing a shot when it's feasible.  No more altitude tent.  No reason to try that experiment again.  I will be cardioverted this week, and we'll see if it sticks.  Modifiable risk factors for most people are alcohol intake (none here), caffeine intake (way too much, already tapering), and overall health--you know, like regular exercise...

I'd felt fairly knocked on my ass for the last few days, but I'm starting to get my emotional if not cardiac mojo back.  If the AFib thing still lingers, it's going to be ablation time, probably sooner rather than later.  I'm going to walk through the standard treatment algorithm of cardioversion--> antiarrhythmics--> ablation a whole lot quicker than most people would.  Color me impatient, but I don't see any benefit to putzing around with non-solutions.

Interestingly, Larry has also been putting in for the Norseman lottery...


Atrial Bleeping Fibrillation, Part I

The last three weeks of Ironman Arizona preparation have been of the "build" variety, meaning a whole ton of time and miles.  Week #2 was 22 hours, with 15 on the bike.  By the end of this third and most recent week, I was predictably feeling burnt.  This was not surprising. 

I recovered pretty quickly with a few days off, with the notable exception of my heartbeat still feeling slow and irregular, which it has for about a week.  I hadn't given it much thought other than it being PVCs/dropped beats, which is not much of a problem, but it occurred to me that it might be atrial fibrillation, which would be.  But atrial fibrillation usually correlates with a faster heart rate.  Yesterday morning, I ran before work--a slow, short, recovery style run.  It felt easy for the most part, but with periods of wanting to stop for no good reason.  When I got to work Saturday, I figured I'd put it to bed one way or another.  So I hooked myself up to one of the monitors in an empty OR:

It's slow, irregular, and lacking the "P" waves associated with a Normal Sinus Rhythm.  So I got myself seen in the ER while working, like a typical bad patient doctor would.  The official EKG showed the same thing: Atrial fibrillation.  As in, atrial bleeping fibrillation, as in, full stop on IMAZ prep and perhaps other things, as in, I'm likely to get cardioverted (shocked) in the next couple days and put on meds to anticoagulate and maintain rhythm.

Educational moment--In the diagram to the right, the EKG waveform for atrial fibrillation is shown on top.  The purple arrow on the lower tracing points to a "P" wave, which indicates normal atrial contraction.  There are no identifiable "P" waves in atrial fibrillation, and a corresponding loss of cardiac power with ineffective atrial contraction.

In hindsight, this was probably not the first episode I've had. When I ran my first marathon back in '99, a trail run near Santa Cruz, I remember feeling funny heartbeats towards the end of the race, and for awhile thereafter.  Soon after that, I remember getting on a treadmill with a heart rate meter (a novelty back then, as far as I remembered), and pushing my heart rate up to almost 190. This may not seem high to some, but currently, my threshold HR is in the mid to high 150s, and my "barf number" is in the low to mid 160s. Relative to the astronomical number I pushed at age 32, I thought my current HR must have been the aberration, a product of subsequent medical school and residency deconditioning or stress. More likely, the earlier, higher number was the anomaly.

I'm not sure where this is all leading, both in the short run and long.  The cardiac possibilities run from cardioversion (low voltage shock) and being basically done with it, to needing ongoing meds and even a catheter ablation procedure if it keeps coming back.  The lifestyle implications are that I need to get off my typical industrial doses of caffeine.  Crap.  I'm a big fan of caffeine.  But I'm a big fan of cardiac output too.  The endurance possibilities run from just having a long taper into IMAZ to having to become basically a recreational athlete.  This actually wouldn't be the end of the world.  But being a non-athlete is a non-option as far as I'm concerned.

I'm reading up and talking to people I know to make sure it's handled the best possible way.  Tonight I'm going to have a phone chat with Larry Creswell, Cardiac surgeon and endurance athlete.


Monday, August 31, 2015

The Ironman "Crankies"

It's been a good couple of "up" weeks of beginning to build to IMAZ, and I've had the first couple instances of the "Ironman Crankies" the last couple days.  Most folks who have been through the preparation and execution of an Ironman know what this is: cumulative physical and mental tiredness, leading to increased irritability, and unfortunately, a corresponding decreased ability to keep the mouth shut about every little thing that bothers me.  The Crankies are a sign of overreaching, a necessary part of gaining the requisite fitness.  But they are also a warning not to push too hard through the exhaustion into full-on overtraining syndrome or injury.

After 3 hours of power intervals on the bike and an hour run in 93 degrees, I got a little fussy at home Saturday.  Karen, experienced IMer and Ironwife that she is, asked where I was in my training cycle.  And then the light went on. 

Awareness is the first step in managing the Crankies.

Keeping my cakehole shut is the second. 

Getting caught up on sleep can't but help, and moving into a recovery week will make it go away almost completely.  But not entirely, thus the need to self-censor.

The Universe must be on my side--I slept all night long last night on overnight call at our Level I trauma center, on a Saturday, no less.

Time for a nice, toasty trail run.


Saturday, June 6, 2015

Doing the Deuces Wild Double

This past weekend marked the beginning of Tri season for me.  Up to now, it's been skiing, Quadrathlon-ing, and mostly Ultrarunning, and more Ultrarunning, with a relatively small side order of swim/bike.  So in addition to avoiding injury and having fun, my goals/expectations were limited.  Show Low, AZ, where the Deuces Wild Triathlon Festival is, sits at over 6,000 feet above sea level, which is more than 3,000 feet higher than our home in Tucson, meaning that oxygen was the limiter, particularly on the swim.  The weather was beautiful.  Just as Tucson was creeping over the century mark, the mercury barely passed 80 in Show Low. 

Just for fun and training, I decided to do both the Deuceman 70.3, as well as the Deuces Wild XTERRA the following day.  There was a kids' triathlon (with the kids' first open water swim) on Saturday, making for a very full weekend at the Fool's Hollow Lake area.  A good number of Tucsonians, many of whom were Karen's fellow Tucson Tri Girls, were there, which made it more social than expected.

In 2011, the Deuceman 70.3 was my first Half IM.  I completed it in a fairly respectable 5 hours and 48 minutes, but that was 4 years and 10 pounds ago.  My two-tiered goals were to either go a full hour faster, or break 5 hours.  I did this one with a sleeved, and admittedly inflexible, wetsuit, with the thought to do the XTERRA swim in a sleeveless wetsuit for comparison.  Historically, I've tried several sleeved wetsuits, but haven't found one that I didn't feel like I was fighting by the end of a HIM or IM swim, so I was curious to find out how fast and comfortable either option was.

The high altitude swim is infamous for creating hypoxic panic in those who go out too fast, so I did my best not to do so.  Despite my best efforts to loosen up the shoulder fabric, I was fighting the wetsuit in short order.  The swim took 31 minutes, slower than expected even with elevation.  I think I was 4th out of the water.  Many agreed the swim seemed overlong, but maybe that was just the hypoxia talking.

Riding off into the pines, similar to my home town of Los Alamos, NM
This was also the long awaited first triathlon on the new Dimond.  Despite having been on it for several months now, I felt funny on the bike for the first 15 miles, and power output was initially low.  I dropped a chain; I missed a turn, but saw the turn markings as I overshot them and got right back in it.  Finally I found my position, and the bike got fun and fast.  The Dimond is amazing.  In spite of the fact that I had a couple miscues and pushed lower average wattage than I did at IMAZ last year, I rode 2:32 on a hilly course that had 2600' of elevation gain (per Trainingpeaks).  Yes, it is a fast bike.  And yes, I can't wait to see what it does at IMAZ this year.

Starting on the Deuceman run
It had warmed up a little by the time I got out on the run, and I stuck with my goal of starting out easy and feeling my way into it, and not overdoing the nutrition on the run.  Again I had to adjust expectations to the altitude.  "Proper pace" was slow, slow, slow for a HIM.  But the run went well and smoothly until the last couple miles, when the tummy started voicing its discontent despite being empty.  I was happy to finish in 4:56, 6th overall, and first in M45-49. 

Definitely a good start to tri season.

Josh (12) and Kelila (7) did the youth triathlons in the afternoon, and got their first taste of open water swims.  Both faced the intimidating prospect with gumption and prevailed! Kelila was 2nd in her AG, continuing her solid tri results.  Much like her parents, she chews up the bike course!

Racin' up a storm!
We have bought or brought oatmeal every
time we've gone to Robin's cabin...
After some dinner and an awards dinner, we retired early at our friends Robin and Rex's cabin, getting rested for the XTERRA.

I approached the XTERRA pretty lightheartedly, and was surprised at how well it went.  The swim was similar to the previous day, only mercifully shorter.  The sleeveless wetsuit was much more comfortable and faster, which makes me think a change of approach may be in order.  The bike course was mostly easy and fun, except for a steep segment with loose rocks, and a corresponding steep downhill segment with loose rocks.  Flowing with the course on a MTB is different than pushing wattage on the road, and in many ways, it's much more enjoyable in both a Zen and adventurous sort of way.  But I'm not as good at it.  The benefit of this is that when I get off the MTB in an XTERRA, I actually get to run people down! The trail run was fun, with a few hilly segments and not too much boulder hopping.  Thanks to the many trail miles I've put in this year, I was able to bounce back easily from yesterday and run only 13 sec/mile slower than I did on the road the previous day.  I suppose slacking a little and having a consequence for it is how one gets motivated to pull it together...don't think I'm ever going to be less than thorough about race prep and execution, even if it's the second race of the weekend and a purported "fun race"/"workout"...

Karen raced the entire XTERRA with one earplug in...
 One interesting footnote: The extensive brown patch on Josh's (green) bike below
is not caked mud, but bees. You can see a few more flying around. As we stood in Subway in Globe, AZ, we saw a swarm of bugs outside, near the car. On closer examination, they were bees. And as we watched the swarm, wondering how we were going to get safely back to the car, they settled enough for me to get quickly and uneventfully into the driver's seat. After 10 minutes of swerving and driving off curbs (and not catching the attention of local law enforcement), about 3/4 were gone, and the gang got safely in. Over the next 90 miles, with several stops and starts, we finally shook off every last one, without a single sting. And courtesy of the Internet, we learned all about bees, swarms, and hives...

Tuesday, March 17, 2015

Monument Valley 50 Miler

My first 50 miler was more of a drive-run-drive duathlon.  I planned to leave Friday after work, and return Sunday morning before a school ceremony for our youngest.  I’d hoped to pull into Monument Valley by 7 or 8 pm, just in time to catch the end of race check-in, but Friday the 13th traffic and an unexpected Time Zone change—the Navajo Nation is on Mountain Daylight time, not Standard time like Arizona—brought me in to the Monument Valley View Hotel at 10:30.   I’d planned a 5 am wake-up to make sure there was enough time to gear up before the 0700 start time, as this was my first 50 miler.   As is often the case before bigger events, sleep was somewhat elusive.  

Nervous.  Not well rested.  Not to worry.
I beat the alarm, and on went the gear—Hokas with gaiters, Injinji toe socks with DeFeet wool socks over them, compression shirt and shorts, cover shorts, a race pack with Camelbak, a waistpack with a nutrition bottle, and, perhaps most importantly given the venue, a point-and-shoot camera.

We milled around in the darkness for a few minutes, as I silently wondered exactly how one started an all darned day run.   My inner Master Yoda answered, “Mmm, one step at a time you go; slowly and comfortably you run.”  That was the plan, at least.  Running more or less from sun-up to sundown is a hard thing to imagine when one’s previous longest run is around 5 hours.

We received a predawn blessing from a representative of the Navajo Nation.  Then we lined up, and, in a relatively unceremonious way, we were off.   Dawn broke after a few miles, and the views were amazing.  Most other runners seemed to have cameras, and photo stops were the rule, not the exception.  The terrain was more undulating and sandy than expected.  After the first couple miles, I revised my expected finishing time estimate from the 10-11 hour range up to about 12 hours.  The segments that were around mesas had more solid footing, and a moderate amount of rock-hopping.   But the terrain was like all other conditions, just something to accept and work with.

Across the Utah line, running towards the Brigham's Tomb aid station.

Looking South at the Valley from across the Utah State Line
One mental strategy for a race of this duration might be to break it down and not think of the entirety of it, but I kept reminding myself of the race length in order to subdue my urge to pursue other runners or push a faster pace.  Mostly, this worked.  Around Mile 14, it no longer helped, as the weight of the race landed on me.  It helped to treat this as another opportunity to pay attention to what I was doing in the moment, and to detach myself from my thoughts and feelings, and just observe:

Wow, so I don’t feel like running, certainly not for another thirty-six miles.  Okay, so noted.  Keep the feet moving, and keep sucking down the nutrition, and it will change.  And then it will change again.  And again...

The "mark" of a true ultra runner.
About this time, I saw a 100 mile runner walking in the other direction, 26 hours and 85 miles into his race.  By the despair etched on his face, it looked as if he was struggling mightily, and when I offered some encouraging words, he brightened like I’d handed him a winning Powerball ticket.  It turns out there was an abundance of encouragement flowing in all directions, and some positive words helped to lift me out of my own funk in short order.   Some of this can be found at times in triathlon, but the sense of support and community at this race was truly inspiring.  Everyone was cheering for everyone else, even the frontrunners.

After the first 22 mile loop, the rest of the race involved three loops starting from and ending at the Hogan Aid Station, which became a sort of temporary community between scenic adventure jaunts.  At my second stop here at mile 27, I decided to give myself a head-to-toe, “full service” aid stop.   A volunteer at the aid station helped me out, noting that I had what appeared to be "Ultra Brain."  Putting together a plan—like taking shoes and socks off—and executing it felt like an impossibly complicated task.  A fair amount of red sand had snuck in past the gaiters, and I had one blister.  So I dusted off my feet, drained the blister, and switched to the "cover all" Raid Light gaiters.  I was at the aid station for what seemed like half an hour, but it turns out it was only ten minutes. 

I also tried something I hadn’t done on long runs, or in triathlons: Solid food.  At 50 mile pace, I managed to tolerate pretzels, potato chips, and a Clif Bar, and to suck down an entire 20 oz. bottle of Tailwind at once on more than one occasion.  As long as I kept the pace reasonable, it worked. I maintained a steady state of fluid, electrolytes, nutrition, and pacing for most of the race.

The "Totem Pole" and friends
A runner trudges through the sand on the scenic southern loop
"Ear of the Wind," at the southernmost turnaround point of the course
"Ear of The Wind," at the southernmost point of the course.
All was well until mile 39 or so, when the springs in my legs seemed to suddenly lose their bounce.  This was unfortunate timing, as Miles 39-43 were the approximately 1,000 foot ascent and descent of Mitchell Butte.  Over the next few miles, I devised a couple of other names for it.  Whatever residual quad strength I had was spent getting up it, and the descent over loose, rocky terrain made my moderately sore feet scream at me.  The turnaround at the top was exultation—I knew I would complete the race. 
Mile 41.5, final turnaround on top of the Butte
The last 7 miles were about how to manage the progressive muscle failure.  First, I power walked, with a little bit of kick on the downhills.  This stride felt about as graceful as doing a Frankenstein impression on cross-country skis, but it was fastest, and I was all about the finish line at this point.  My power walking speed was initially not much slower than my dwindling running speed, but even that eventually collapsed to a walk up the long final hill to the finish line, 11 hours and 42 minutes after the start.

Two fellow racers almost caught me right at the line, but somehow I found just that little bit of reserve to stay ahead.  The utter failure of leg muscles was beyond even that of an Ironman by quite a bit.  Shivering and limping, with spasming hip flexors, I barely made it to the car, where I cranked up the heat and began convalescence.  It occurred to me to take a final picture of the view before I left, but the body was no longer capable. 

Looking North from the top of Mitchell Butte
The race was amazing, not just in terms of the course.  The aid stations were excellent; the feeling of community among the racers was like nothing I’d experienced.  I’ll definitely do another one, and probably one that Matt Gunn put together.

Just not next weekend.