Picture this. It is the middle of the night at World's Toughest Mudder and you are in pain. You feel like each step is almost like stepping into a pool of cement. You are hoping that further along the course there will be a smile or a light in the darkness so you trudge on. You finally get back into the pit area and you are not feeling right at all. You hesitate, wondering if you visit the medic tent if they will pull you off course. Then you see Molly, an angel in the darkness. You feel better knowing you are in good hands.
I wanted to format this Badass Women of OCR article a little differently.
Molly is a woman whose main goal is to ensure you get back on course as healthy as possible. I felt it was important to share her story, as there is a huge misconception that once you are in the medic tent your race is done. I am going to let her tell her story in her own words.
Tell us a bit about yourself.
I work as a family nurse practitioner (FNP) in Sacramento, CA in both primary and urgent care clinics. A nurse practitioner is someone with their Master’s degree or Doctorate in nursing. We are similar to physician assistants (PAs) in that we can diagnose, prescribe medications, oversee chronic and emergent health issues and make treatment plans. Additionally, I work for Med Prep Group which is Tough Mudder’s contractor for medical services. As a provider, I am stationed in the med tent which, only at Tough Mudder, is fully staffed, stocked and able to treat you. We will do everything we can to treat you and turn you right around and get you back on course. At World’s Toughest Mudder 2016 doing neuro checks overnight, I was approached by a bloody athlete. I put stitches in his chin and him back on course in less than the thirty minutes that an athlete is allowed to spend in the med tent before disqualification. He went on to get his 75-mile silver bib.
One of the great privileges I’ve had this year has been to work with Jason Nicholson who is an accomplished OCR athlete that quite possibly could have died after WTM 2016 because he followed mainstream advice: drink lots of water and if it hurts, take ibuprofen. While those things may work in everyday life if you project that out over 24 hours of intense activity they can be fatal. The book Waterlogged: The Serious Problem of Overhydration in Endurance Sports, by Dr. Timothy Noakes, includes many stories of unnecessary deaths from over-hydration during or within the 24 hours following endurance events. Jason’s first mistake was that he went into WTM with a set plan of how many calories he needed to support his efforts and depended largely on sports drinks to obtain these calories. He topped that off with a lot of water. He survived the course with a stellar 65 miles but over the next two days become progressively sicker finally walking himself into the ER only to be told that he was gravely ill.
What was your first OCR event? Please tell us about it.
The first OCR event where I worked medical was TM Tahoe 2016. Med Prep Group is so awesome that there they have two medical tents. One at the base and the other mid-mountain. Arriving early I found myself alone at the mid-mountain site and was astonished at the supplies and capacity of what I could treat. Next event you do go to the med tent and ask them if they’ll do stitches and then let you go running again. Everything you need to know about that company and their ability to support you as an athlete exists in their answer.
That day in Tahoe athletes kept asking me if I had ever done a TM. I hadn’t and was fairly certain I wouldn’t for a long time. However, several months later at TM Lake Elsinore I worked Saturday and ran Sunday and it was life-changing. The way strangers just climbed in to help me and refused to let me fail or give up. At 5’9” and considerably overweight, I can connect with people because I don’t have the intimidating super body. I am the bottom of the OCR barrel and yet on a TM course, I am the only one that reminds me of that. I worked WTM 2016 and my plane hadn’t even lifted off the ground to come home and I had made the commitment that I would be back as an athlete. I trained all year, even to the point that I injured myself pretty critically with musculoskeletal overuse but despite that and being way more overweight than I wanted/had planned I did hike the entire 24 hour event getting four official laps and possibly being one of the few people that can say, with a smile, that I took every single penalty with the exception of Pandora’s box. The way that I was embraced on that course was astonishing. Strangers repeatedly, and without complaint or even comment, stepped in to help me up, over, though. There were no complaints about my weight and I got the sense that my success was as important to my fellow athletes as it was to me. I was able to help a few people on the course and a lot of people helped me. There are many reasons that I keep coming back to TM but the ethos of camaraderie is the one I’m addicted to.
From experience, what is a huge medical risk that you have seen OCR racers in endurance events take?
Over-consumption of fluids is the biggest risk factor in exercise-associated hyponatremia (EAH) where the level of sodium in your blood gets low. The first sign of this is actually swelling of the hands and feet which most OCR athletes have experienced perhaps without fully understanding the significance. We lose sodium when we exercise, this is normal and expected. We cannot replace it with any sports drink and so drinking to excess means we can really dilute ourselves. It’s the combination of losing salt and taking in fluids that are less salty than we need that creates this problem. After the hands and feet swell there may be further signs of EAH include nausea/vomiting, headache/confusion and later seizure, coma, and death.
From experience, what do you find for an OCR racer or competitor is the number one thing they can safely carry on them?
I recommend that people take in supplemental sodium by bringing along with them plenty of salty options and taking them in when the body says to. Bodies are smart. People are stupid. You can absolutely over-think this one. There is no set amount of salt to take in during a 24-hour endurance event because each person will lose and need salt differently. Bacon, pizza, potato chips and pickles are great sources of supplemental sodium. Some people take in salt tabs although you should know that there can be too much of a good thing. Too much salt will actually cause water retention and comes with a whole host of other problems including increasing your blood pressure and cardiac workload. Lastly, the reason that I carry salt packs on me (and encourage others to do so) is that according to the neuromuscular theory of cramps a salty snack will break an acute cramp in a fraction of the time. I have helped innumerable cramping athletes just by handing them a salt pack or two. This is too fast to affect serum sodium levels to be affected.
In the same respect, what is the one thing that an OCR racer should never carry with them on course / administer to themselves?
Another big issue is pain and pain management. Ibuprofen belongs to a class of medications called NSAIDs (non-steroidal anti-inflammatory drugs) which includes Motrin, Aleve, Advil, Mobic but not Tylenol. Tylenol (acetaminophen) is cleared by the liver so it is considered safer, in small amounts, during and after endurance events. By contrast, the NSAIDs are cleared by the kidneys and reduce blood flow to them. Recall that the kidneys are the body’s filtration systems and when we exercise in an ultra-endurance event the kidneys are working extremely hard. Reducing flow to them is the last thing we want to do. A recent Stanford study found that use of ibuprofen during an endurance event doubles the athlete’s chance of acute kidney injury. If your kidneys fail you require an outside machine (dialysis) to clean your blood. When Jason’s immense cramping started three laps into WTM he used 15 tabs of Advil over 12 hours largely because it was easily accessible and he had no previous issues with it despite comparable events. He may have had a vague concept that ibuprofen wasn’t great but land in the ICU for a week? No, he was not ready for that. He did survive, and we are all lucky for that because his attitude has been one of reflection and education. You can listen to him and I talk about it with Will Hicks on Will’s World’s Toughest Podcast episode 41: How to not die at World’s Toughest Mudder.
What do you feel is the biggest misconception at large events when a medic approaches and tries to help or when someone needs to visit the medic tent?
I have observed athletes as fearful of medical staff and I can tell you the appropriateness of this sentiment varies by company. OCR companies use different medical contractors for medical services with very different policies, procedures, resources, and attitudes. A representative of the medical contractor for a non-TM OCR company told me that they “operate on a first aid basis” and that as a medical provider I could not treat only end races, use ambulances and send people to the ER. I declined work with that company.
Take the example of vomiting. There are lots of reasons an athlete might vomit at an event from mundane to serious. At TM I can take the time to assess the difference, give medication and get you back running. Now imagine if an elite athlete is vomiting on another course and the policy is that the act of needing medical care is an automatic disqualifier. What has that accomplished? You’ve taught the athletes to fear and resistance and you’ve quite possibly turned a mundane issue of stomach upset into full-blown dehydration and electrolyte imbalance. Because we all know you’re not going to quit, and we don’t want you to quit, we want you to succeed. Some policies and companies do unintentional harm. For that same company, even the non-elite are railroaded off the course.
Is there a fun nickname you have been given by racers or other staff/volunteers?
At World’s a pit neighbor saw my table full of free supplies to share; salt, mustard and honey packs, candy, peanut butter and graham crackers, Ziploc bags to take it all on course with you. She said, “you’re Medical Molly” which my pit crew promptly wrote on the back of my bib. I also write small red crosses on my bib next to “M. Kenneth” because carrying my family name on course is important to me and because I want people to know they can lean on me. I make it perfectly clear that I am not in a medical role and do not replace medical help but at the same time athletes are encouraged to help one another and there’s no way you’re going to put me on a course and I’m going to suddenly stop being me. It’s not like I’m in a hurry or a contender for prize money. I’ll stop and talk to anyone about anything. It makes me feel normal.
I know this isn't an easy one, but what does it mean in your eyes to be a Badass Woman of OCR?
If I’m viewed as a Bad Ass Woman of OCR then let it be because I have taught people how to do what they love and need in a way that’s safer. First, let it be because I have prevented their injury or illness and only second because I have treated it. If me losing sleep means we all get more miles then I’m all for it. I put information out there that can be scary but I will always do it in the angle of prevention and the goal is to empower rather than frighten. At the end of the day, the athlete’s # 1 resource is themselves and secondarily, other athletes. The medical staff is actually the third line of defense and barring something stupid and unfortunate if you prepare well you should never need medical help. But the responsibility is on you. I don’t care how many burpees or pull-ups you can do if you can’t manage your intake or your pain you’ll crash and burn in an ultra-endurance event. I can teach you what you need to know to prevent that.
Is there anything else you wish to share with us?
I am most interested in the systemic issues that can come with prolonged activity. There are always going to be the sprained ankles and the jarred knees but that’s dumb luck. What I love about the longer events are those small things done wrong projected out over time can have very serious, including fatal, results. Even some members of the medical community don’t understand the total meltdown an athlete can achieve when they run their serum sodium low, what that looks like and what it means to their system and organs. I like the term “endurance medicine” because it captures that unique nature of our sport. Endurance medicine is not emergency medicine outside. Originally trained as a wilderness medic I am crafty and thoughtful; an expert at assessing my resources. I know that you want to keep running because I know I want to keep running. So how do I help you get that done?
I think it is only when the athletes ask for better care at all OCR events that we will see a trend toward more common sense medical interventions that support athletes rather than railroad them into an ambulance to the ER. In two years of doing this, I have sent exactly one athlete to the ER and I have disqualified zero. That being said, I have watched plenty of wheels fall off and people disqualify themselves secondary to inadequate preparation. I’ve done stitches, helped to relocate shoulders, started IV’s, run EKGs. I’ve worked other endurance events, including prized hundred milers, and TM is the only place you’ll see this type of support for athletes. At your next OCR look around and ask around. Medical care should support you to continue. If it is either absent or with policies that don’t support you let that company know that you prefer the model Med Prep Group utilizes: catch and release. Medical staff should be a resource you feel comfortable accessing, where you can be assessed, treated and put back on course. No one should take your event away from you, unless you really need it, and it shouldn’t’ be over anything stupid and preventable because you have educated yourself and trained hard. Being truly well trained and ready for your next ultra-endurance event means you know how to use fluid, food, salt and no NSAIDs to achieve your goals.
But at an event relying heavily on ambulances for medical services paired with the knowledge that virtually everyone in an ambulance receives an IV of hypotonic (less salty than you) solution you should know to not let anyone start an IV on you unless EAH has been ruled out. In acute EAH a large volume of not salty fluid can be fatal and if not fatal may leave you so brain damaged that death might be the preferred option. The policy at TM is to not start an IV on you until your blood chemistry; including serum sodium has been checked. Even without the fancy i-stat machine that runs blood in two minutes, clinically, dehydration and EAH look very different and giving every endurance athlete an IV because they’re “probably dehydrated” is reckless. Small amounts of very salty boiullaine work in the conscious athlete with moderate EAH. Severe cases are treated with a small amount of very salty fluid (3% hypertonic saline 100 cc’s) via IV every ten minutes.
Ask the doctor at your next event about their EAH protocol. If they can’t answer you or motion towards an idling ambulance be very afraid. What works on a short course doesn’t work in a long event and unfortunately, I’m afraid one of us is actually going to have to die this way to bring the point home. I’m doing what I can to change that, but I don’t know it is fast or good enough. There are veteran athletes that are probably sick of my voice and ideas and I’m okay with that. Because we all want OCR to grow and include new people, and new people need information and I know every day I am learning as an athlete and in medicine and I recommend no one shut off learning. Because we WILL learn, it’s up to us if that is proactive and helpful or reactive and event ending.