Aug 232013
 

The Pikes Peak Marathon is an iconic mountain trail race that exemplifies most of what I love about mountain running. Sure, there are some aspects of the sport that aren’t highlighted at Pikes Peak. It isn’t particularly “technical” in that the Barr Trail is wide, easy-to-follow, and relatively smooth. (Kilian Jornet called it “flat.”) It isn’t an “ultra” distance like many top mountain trail races (Hardrock, for example, or the UTMB), meaning it doesn’t require you to run through the night and into the next morning. But it is long enough to test your endurance, and short enough to test your speed. There is a lot of sustained uphill (and downhill) running at very high altitudes. There are steeper parts and flatter parts, that test your power and your aerobic conditioning. The views are beautiful. The quality of the field is excellent; several of the world’s best mountain runners come to Colorado Springs every year for this race since it is part of the world skyrunning calendar. You don’t have to be an elite runner to do this race, but you do have to qualify to enter.

The Pikes Peak Marathon course from Manitou Springs to the summit and back

The Pikes Peak Marathon course from Manitou Springs to the summit and back

The 2013 PPM was my first since 2001. My goal was to finish in less than 7 hours, because that’s the qualifying time cutoff to enter next year’s race in Wave 1. I did achieve my goal, and I’m very happy about that. On the uphill I felt generally pretty good, but once I got above Barr Camp I didn’t have the power that I’d hoped to have, and I had to start hiking sooner than I’d expected. Even then, I managed to get to the top in 3:47, which beat 3 out of 4 of my previous ascent times.

The downhill, however, was mostly a disaster. As soon as I turned around on the summit and ran downhill for a few meters my stomach started giving me problems. With every footfall my lower abdomen actually hurt, and I wondered whether appendicitis felt like that (lucky me, never had appendicitis!). By the time I got close to Barr Camp on the downhill trip the jarring pain had been replaced by nausea. I had to stop at the Barr Camp aid station for fifteen minutes to drink and eat and grimace a lot. I thought the sub-7hr goal was slipping away, and it would have had not I been lucky enough to feel better for the run down from Barr Camp to No Name Creek and the top of the Incline. That stretch actually felt pretty good — no nausea and none of the joint or muscle pain that’s common for such a sustained downhill. I wasn’t running hard, but I managed to pass plenty of people on that stretch who I’m sure were all fighting their own pain problems of one sort or another. By the time I got to the top of the Incline I knew the sub-7 was in the bag.

Unfortunately, the trail steepens past the Incline summit and that final downhill turned into a sufferfest. I had been protecting two big heel blisters I’d picked up the week before at the Telluride Mountain Run Hill Climb, and now the balls of my feet and toes felt gangrenous and ready to fall off. The nausea had returned in full force. Any attempts to run (let alone run fast) made me feel like throwing up. I admit that the certainty that I’d finish in less than 7 hours, but over 6 hours, sapped my motivation to extract speed on that last miserable section, because what was the point? So I basically walked in that last mile, and finished in 6:43. If I had dug deep I might have finished in 6:20 or something, but at the time that difference wasn’t worth the additional pain. Wimp!

Happy to get back down to the finish

Happy to get back down to the finish

So, that’s how the race felt. Some bad, but mostly good because I’d done what I’d set out to do. Post-race, though, it’s fun to do some analysis, and try to learn as much as you can about how to get better. Hence, numbers.

Thanks to the great people at the Pikes Peak Marathon and their super-duper timing technology, I have a lot of numbers. Here are my splits for the 2013 race:

 

NNUp      0:56:54     0:56:54

BCUp       0:42:53     1:39:47

AFUp       0:50:40    2:30:27

Summit    1:16:57     3:47:25

AFDn       0:44:46     4:32:11

BCDn       0:47:20     5:19:31

NNDn      0:30:38    5:50:10

Finish      0:53:15     6:43:25

Descent   2:56:00

 

The first column of numbers is the time elapsed since the last time check, and the second column is the cumulative time elapsed in the race. The splits are from No Name (NN), Barr Camp (BC), and A-Frame (AF, which is at timberline).

To give you a sense of what these numbers mean, here are the splits from Dave Mackey, one of the world’s elite ultra runners who is listed as 42 years old (same as me), and who finished 6th overall:

 

NNUp      0:44:33     0:44:33

BCUp       0:32:41     1:17:14

AFUp       0:33:40    1:50:54

Summit    0:46:40   2:37:34

AFDn       0:22:52    3:00:27

BCDn       0:16:54     3:17:22

NNDn       0:20:46    3:38:08

Finish       0:23:51    4:01:59

Descent     1:24:25

 

You’ll immediately notice that Mackey’s times are much faster. That’s not too surprising. The interesting thing is that for some of the splits, his times are better to a much larger degree than for other splits. There are a ton of racing lessons buried in here, just waiting to be extracted and used for future races. Obviously the two big ones are that I need to run uphill faster, and I need to run downhill faster. Duh. But let’s look more closely for some more helpful, more specific lessons.

I think these splits say two big things. I need to get faster at high altitudes, and the downhill is killing me. Comparing my times up to AF and the summit with those of Mackey (way ahead) and with many of the runners that had similar times as me up to NN and BC, I pretty clearly slowed down relative to the field above Barr Camp. Of course, it might  just be that I went out too hard up to NN and BC. While that’s certainly possible, that doesn’t fit with how I felt on the course. I don’t think it’s just a matter of endurance, either, since I’d been doing plenty of four-hour runs and I’d be surprised if I just ran out of gas two hours in. I’m convinced that the ticket to getting a really good time (a subjective thing, I know) in the ascent or the marathon is being fit enough to actually run the trail above the A-Frame to the summit. If I can manage to do that, my ascent time will drop like a stone.

But the downhill is really where I have the most low-hanging fruit to pluck. Run down, instead of hobble; avoid the 15-minute spell in the chair doubled over at Barr Camp, and I could take an hour off of my descent time without getting any fitter or stronger. Earlier this summer I ran down from the summit with my dog in two hours. My challenge is to feel good enough to get down in at most 2 hours during the race. It’s a doable goal, but I think it’ll take a lot more specific training than what I did this summer. Instead of one trip down from the summit I’d like to do at least 5 or 6. First, run, then think about running downhill faster.

Descending Barr Trail between the A-Frame and Barr Camp with Pele on a training run

Descending Barr Trail between the A-Frame and Barr Camp with Pele on a training run

I suspect I’m also making technical errors on downhills generally, because why else would I be suffering from such bad blisters? For this race I wore two socks on each foot, and they helped a lot (my heel blisters didn’t get any worse). So that’s a lesson learned. How to prevent ball-of-foot blisters, though, is probably in part a matter of running technique and form. I’m probably leaning back and heel striking too much. There is a strong argument for working with a coach for a few sessions to improve my technique.

Anyway, a big thank you to all the aid station volunteers (and especially those at Barr Camp!) for keeping all of us going on race day. Hopefully I’ll be able to do this race again next year with another season of training under my belt, and do it under 6 hours. Then next year, under 5. Then next year, under 4. Then next year….  OK, yeah, not so much.

 

Aug 192013
 

strokeassociation FAST

One of the most difficult tasks required routinely of ER doctors is obtaining informed consent for the use of IV tPA in cases of acute ischemic stroke. It is a difficult task because it combines two things that are each — standing alone — among the most difficult things ER doctors are expected to do.

First, we have to decide for ourselves whether or not we want to give tPA. This is an extremely difficult clinical decision. There is a substantial risk of causing catastrophic life-threatening hemorrhage and other serious harm; tPA is not a risk-free treatment. The decision to give tPA must usually be made under conditions of severe time pressure. Studies and guidelines suggesting that tPA benefits victims of ischemic stroke emphasize that it must be given within a very short time period after the onset of symptoms, usually three hours. To complicate matters, the scientific evidence supporting the decision to treat acute ischemic stroke with tPA is not obvious or clear. It is perhaps the most controversial current debate in emergency medicine, with passionate supporters and opponents all wielding literature that is inconclusive and incapable of resolving the debate.

Second, given the risks of tPA, modern medical ethics demands that before we push the drug we explain to the patient or her family members the risks and benefits of treatment to the extent that they are able to give their “informed consent.” In the best of circumstances, obtaining truly informed consent is very challenging. But the circumstances surrounding the tPA decision could not be worse for the patient or family member of the patient — the clock is ticking; they have to make the decision quickly. They are being asked to weigh highly incommensurable outcomes against each other, e.g. death from intracranial hemorrhage, or regaining the ability to speak. In many cases a family member asked to make the decision at one remove — not what I want, but what would my family member want were she able to make the decision for herself. And, of course, the honest physician will inform the patient that the scientific evidence for tPA is not ironclad, and that there is a raging debate among doctors about whether it is beneficial, useless, or harmful.

“So, after all that, what do you want to do, Mrs. Jones? You have, let’s see, about 15 minutes to make your decision.”

My own approach to this difficult task has evolved and will evolve further as I accumulate experience and as more scientific evidence surrounding tPA (and surrounding informed consent) is published. But for now, this is how I approach the problem.

1) It is impossible to familiarize the patient or her family members with the entirety of the tPA evidence in the time they have available for making their decision.

It takes many, many hours for emergency physicians and neurologists to digest the tPA literature; so much so that most busy clinicians rely upon trusted intermediaries to digest the literature for them, pro and con. To then expect that you will be able to fully inform a layperson within the allotted time who is already in great distress from seeing their loved one suddenly immobile on one side of their body and unable to speak is fantasy. So don’t try. It won’t work, and you will be wasting precious time.

2) The goal should be to help the patient or her family member to make a decision that they will be least likely to regret should the outcome turn out to be unfavorable.

Regardless about what the decision about tPA turns out to be, there is a significant chance that the outcome will be far less than perfect. The patient may refuse the tPA and end up paralyzed and fed through a PEG tube for the rest of their lives. Or, the patient may choose the tPA and suffer a fatal intracranial hemorrhage. Post hoc, it will be impossible for anyone to say if the outcome would have been “worse” had the patient made the opposite decision. I don’t think that having a more subtle understanding of the NINDS trial, or being told about the difference between the Cochrane metaanalysis of stroke studies and the ACEP guideline’s review of the tPA literature will do much to alleviate regret if, in this one case, the outcome is bad. What will help is if, in hindsight, the patient’s family can say that the decision was consistent with the patient’s values and overall approach to risk.

3) To maximize the chance that this will be the case, the doctor’s discussion with the patient or the family member should emphasize three informational elements: a) the near clinical equipoise of the published studies b) the choice between potentially reversing the disability caused by the stroke with tPA, and the potential for that drug causing possibly fatal bleeding c) your personal enthusiasm for or against tPA, if the patient asks.

There is rarely enough time for a discussion of much more than these three things, and in the end, these are the three things that matter most for the decision.

4) Remember that the patient or her family member is not being asked to take sides in the controversy over the tPA evidence.

They are being asked to share in the decision making about whether tPA should be given here, now, in this particular case. This is not the same thing as taking sides on the issue of whether routine tPA should be the standard of care across all cases of acute ischemic stroke.

5) Translate the decision into one that the patient is familiar with after a lifetime of making their own high-stakes decisions under uncertainty.

In general, this is the choice between “doing something” to perhaps improve the situation, vs avoiding iatrogenic harm.

Most patients that physicians see tend to fall into one of these two camps. The former will actively take all kinds of medications and seek out all kinds of therapies for even the most subtle of symptoms. The latter will wait until the last possible moment to take that daily aspirin for their heart disease or to see that surgeon for their postprandial right-upper-quadrant pain, in order to avoid iatrogenic stomach ulcers or an inadvertent surgical sponge in the abdomen. If physicians are honest, they will admit that much of their own enthusiasm (or lack thereof) for tPA in stroke is guided by their own tendency to either “do something” or to avoid causing harm.

This choice between action under conditions of uncertainty vs avoidance of action under uncertainty is something that we all, regardless of background or education, understand. It’s a choice that’s fairly thoroughly informed by our general values and approach to living. When faced with the problem of water pollution, for example, some of us dream of huge water processing plants and massive pipelines; others of us dream of discontinuing the production of toxic waste. Faced with the possibility of a stock market crash, some of us short a bunch of stock, others of us put all our money in cash under the bed.

I like to ask my patients “are you a “do-something” kind of person, or are you a “don’t screw things up” kind of person? I tell them frankly that they, or their loved one, is in a very bad position and that the uncertainties are huge. I tell them that the outcome could be tragically bad whether we give or don’t give the tPA. I say that I understand that they are being asked to make a difficult decision in a situation with a high degree of uncertainty and a high likelihood of extremely consequential results, either way. I offer to answer any questions that they have, to the best of my knowledge. I will give them my opinion about tPA: not enough evidence yet to say whether it’s helpful, harmful, or inconsequential — a scientifically unproven therapy that deserves further study.

“So after all that, what do you want us to do, Mrs. Jones?”

Ugh. This is why I’m a fan of doing all we can to prevent ischemic stroke.

—-

Some links I like:

ACEP clinical policy on tPA in stroke [PDF]

David Newman’s SMART EM podcast on tPA evidence

Dr. Newman’s blog post on same topic

Links to Cochrane review of thrombolytics in ischemic stroke

BMJ debate about tPA (and steroid) guidelines and conflicts of interest

 

Aug 142013
 

Plunging downhill and nearing the finish of the inaugural Telluride Mountain Run Hill Climb (“Hill Climb”), I had just passed the second-placed female and moved into 5th place overall (fourth male). I was trying my best to run like Ellie Greenwood, who’d flown past me early on the descent and left me wondering a) how that speed could possibly be good for her lower-extremity stress fracture, and b) whether I could ever learn to run downhill that fast. That’s when I started to feel the skin peeling off of both my heels. Uh oh — I was going to be in trouble real soon…

It’s been a few days since the race, and I’m still riding the post-race high. I’m also hobbling around like a duck because of the massive blisters on both of my feet. I don’t know if the blisters will heal in time for the Pikes Peak Marathon this Sunday, but even if they don’t, the Hill Climb will still have been totally worth it.

I’ve been trail running seriously for almost two years*, which at my age (middle) isn’t a hugely long time. Most of that time has been spent watching YouTube videos of famous runners running famous races, people like Kilian Jornet Burgada (whom I named my dog after — it’s a long story), Ellie Greenwood (who was actually on the same course with me at the same time, OMG!) and Dakota Jones (who was one of the race directors of this painful but delightful little race). I have spent a lot of time on trails in the Seattle area and in Colorado, running up and down hills, around trees, through mud, in rain and snow and cold and heat. While I have had fun on every run, I have often wondered whether any of it was making a difference in my ability as a trail runner. Well, I still have little objective evidence of any improvement — I don’t faithfully time myself on the same routes or repetitively try to beat my PBs on a given trail (hey, I’m not Anton Krupicka). But my subjective experience at the Hill Climb is that yes, I’m getting better. That is hugely motivating.

On to the blow-by-blow, which in an eight mile race isn’t going to be a long drawn out kind of thing. I could paraphrase Dakota after his 2012 Lake Sonoma 50 victory: “I ran alot, and then I finished sixth.” But I know you want to know what it was like, so I’ll elaborate.

1) Cameron Clayton disappears: It was fun to start the race in the same small field as elite runner Cameron Clayton, who had just come off an uncharacteristically low (for him) 14th place at Speedgoat against a world-class field. As we started to climb, he moved out ahead of the pack by about ten feet, turned back and said something like “anyone coming with me?” and then took off up the hill and disappeared into the distance without anyone going with him. I can’t be sure that’s what he said — I was surrounded by the sound of huffy breathing and stomping feet, so I might have heard wrong. Anyway, it was exciting to run alongside him for about fifty yards or so. This is why trail racing is so fun!

2) Mucus Monster. I caught a cold a few days before the run, and this resulted in massive quantities of mucus in my upper respiratory tract, which extruded itself during the race on account of all the heavy respirations I was doing. This didn’t seem to slow me down during the race, but it was annoying and probably very unsightly. Good thing I’m not a sponsored runner who has to look good for the photographers!

3) Steep as Sh#t: This course was steep. Which meant that most of my climbing was done in power-hiking mode. It was amazing to watch Cameron Clayton and Marco Zuniga actually run that grade, and even more amazing to watch Simon Kearns (age 13) do the same. Both of them took off right from the start and I was sure I’d never see them again on the uphill.** I climbed more-or-less (OK, slightly less overall) at the same rate as former Imogene Pass Run winner Kari Distefano, me passing her, then her passing me. Her style was to run the whole thing — I guess it’s just a matter of what gait is most efficient for you.

3) “Beating” Ellie Greenwood: I reached the turnaround point at the top of Gold Hill ahead of Ellie Greenwood. That is amazing. Yes, I know that she does not consider climbing hills to be her strength. I know that she had just arrived in Telluride from sea level. I know that she had not raced for months because of a stress fracture. I know all of those things, but still — Ellie Greenwood! For the non-cognoscenti, I mention that she was the one who finally broke Ann Trason’s record at Western States. Then there is Comrades, and the long ultrasignup.com list of almost unbroken victories — read all about her as much as you want, and then you will understand that it was exciting to get to the top of the hill ahead of Ellie Greenwood. Even though she was far from full strength. It was cool!

4) Being blown away by Ellie Greenwood on the descent: Soon after the turnaround at the top, Ellie Greenwood blasted past me on the descent. Which reassured me that I was not running in some alternate-reality universe. Before she disappeared down the hill, I paid close attention to how she was running the downhill, and while I can’t claim to have learned any super-secrets, I will say that I saw her running very fast. I will try to put this lesson into practice in future races.

5) Battling Kari Distefano: She and I had traded places a few times on the ascent until she pulled away slightly just before the top. But on the descent I found that I was gaining, and that was exciting! I knew that if I pushed just a little bit harder that I would beat her to the finish. So I pushed. And I passed her!  And then the skin peeled off my heels, and I was running on my toes to avoid the pain of the heel blisters, and my calves started cramping because I was running on my toes, and she passed me, and I finished sixth overall instead of fifth. Drat. It was also disappointing to have to hobble past Ian Sharman who was taking pictures near the finish, but hey, I will survive.

To sum up, the Hill Climb was a great experience. Dakota and Reese were right on two counts: there were mimosas at the aid station, and I did finish in the pain cave. It may or may not have been a sign from God that yes, all my trail running has made me a better trail runner (I’m militantly agnostic about the existence of God, you see), but it has motivated me to keep trying to get better, and to keep racing. I thank everyone who ran faster than I did: Cam Clayton, Marco Zuniga, Patrick Hummel, Ellie Greenwood, and Kari Distefano — you all inspire me to get faster.

I thank the RDs for all their hard work. As a runner, I look at the race directors the same way I look at the hosts when I go to a party: I’m glad you do it, because I would never want to do it! All the planning, all the preparation, all the clean up… whew! Thanks for the pint glass. I needed another one of those. Thanks for the T-shirt; it’s one of the best-looking ones I own. I hope this race happens again next year. Ideally, I’d like to see the hill climb done a day before the long run, so the hill-climbers could volunteer at the mountain run (or do them both). In a perfect world, I’d like to be able to do this race with my dog, because running with my dog is always better than running without my dog. But I realize that yes, the permits are tough enough to get without allowing dogs, and probably impossible with allowing dogs. But I can dream… dogs!

* I have done the Pikes Peak Marathon three times, and the Pikes Peak Ascent once, back when I was in medical school, but I didn’t really train for those races and wasn’t training for anything else, either.

** I did manage to pass Simon right near the top of the hill. Cameron, well… I saw him on his way back down. Briefly.

 

 

Aug 082013
 

The House recently voted down an amendment by Justin Amash (R-MI and a former classmate of mine at the University of Michigan) to defund mass NSA surveillance. The breakdown of the vote is interesting. It was thoroughly nonpartisan, as it roughly split the Democratic and Republican caucuses in half. It also neatly split the House leadership from the rank-and-file, as Nancy Pelosi joined with John Boehner and virtually the entire House leadership in voting against the measure.  Democratic party booster and serial email spammer Debbie Wasserman-Schultz (D-FL) voted on the same side as the right-wing warmonger Peter T. King (R-NY). The opposing camps on this issue can’t be neatly described by the shorthand political terms we commonly use.

I suppose that because Justin Amash himself is a self-styled libertarian, we might be tempted to say that the vote on his amendment revealed a previously undiscovered groundswell of libertarian sentiment in the Congress. That’s true, but only in the sense of “if opposition to unchecked secret surveillance is libertarian, then we are all libertarians” — which isn’t very accurate or helpful.

A digression: I am fond of making fun of libertarians. I like to find examples of others (from Alain deBotton to China Mieville) who skewer libertarianism in witty ways. I think libertarianism as commonly described by its proponents is a thoroughly junior-high-school, adolescent political philosophy that is only marginally more helpful for navigating in the real world than anarchism or communism [and I will admit that I was explicitly an anarchist… when I was in the 8th grade]. Although some of my most intelligent friends call themselves libertarian, I take that about as seriously as they take me when I self-identify as an ancient elf from Gondolin.

But back to the subject: the Amash vote shows that there’s an important political split on one of the most vital issues of the day that isn’t captured by our common shorthand terms. So we tend to mis-label the sides, or worse, fail to notice often enough that it exists. So let’s think more about what the disagreement is really about. What else do the defenders of current NSA practices have in common? What beliefs does Barack Obama share with Peter King and Eric Cantor? Allow me to speculate.

One thing might be a belief in the seriousness of the threat of terrorism. If you really do think that your own life or even your entire country is in imminent danger from terrorists, you’re more likely to forgive secretive methods (almost any kind of methods) to respond to the threat.

Another might be a belief in the vastly superior effectiveness of blanket surveillance to defeat the threat. This might mean that you’re OK with keeping secrets and violating laws for purely utilitarian reasons — the other alternatives simply won’t work. If anyone out there seriously believes this, I wish they’d be more explicit about it.

You might instead be someone who simply trusts authority figures, i.e., you might be an authoritarian. I don’t mean to use this word in a pejorative sense. I simply mean that you might, contra Amash and his supporters, feel comfortable with a world in which government authority figures are given carte blanche to do whatever they feel is best for the country, and you aren’t troubled by the risks that those people might make grave mistakes, or be corrupted by power, or use their power to advance ends that they haven’t told you about and that you haven’t consented to. All of us, after all, believe this to some extent, or there wouldn’t be any such thing as “consent of the governed”, no “representative government.” Trust in authority falls on a spectrum, and the more authoritarian and credulous end of that spectrum is more likely to be untroubled by secret government surveillance, secret law, and unchecked executive branch power.

I think that some combination of these beliefs are shared by most of the people who aren’t outraged by  the NSAs surveillance regime. There are certainly other reasons not to be outraged,* but I’m betting that these three together capture most of what motivated people to oppose the Amash amendment and to prefer to focus on Snowden himself rather than on what he revealed about the government’s activities.

And what about the other side? Certainly a belief in “libertarianism” as freedom from surveillance motivates many of Amash’s supporters, but what else? There’s got to be something, since the Congress did not suddenly become one-half libertarian when Amash’s amendment came up for a vote.

Apart from blanket surveillance itself, the secrecy surrounding this surveillance is troubling. The lack of Congressional oversight (see James Clapper’s lying to Ron Wyden) and the classification of the FISA court’s decisions regarding the NSA’s programs will worry anyone who believes that inter-branch checks and balances are necessary to prevent abuses of power. The less authoritarian, less trusting, and less credulous you are, the more you’re going to oppose the NSA’s unilateral implementation of blanket surveillance, even if ultimately you don’t object to the surveillance itself.

There is a third reason why the NSA revelations are so odious to so many — the apparent disregard for the rule of law. It takes a lot of hoop-jumping to avoid the conclusion that vacuuming up everyone’s email and phone records regardless of individualized suspicion falls under the powers authorized by Congress when it passed the AUMF against AlQaeda, or that it fails to violate the Fourth Amendment’s prohibition on unreasonable searches and seizures. Coming on the heels of the Addington/Yoo era at the OLC, where corrupt lawyers contorted themselves to whatever degree was necessary to condone torture, and following the Obama administration’s absurd redefinition of the word “imminent” to mean whatever it had to mean to justify its targeted killing programs, many of us are far less likely to trust in lawyerly machinations when it comes to the legality of mass surveillance by the NSA.

So what to call the two sides in the split over NSA surveillance? Tyrants vs constitutionalists? Terroristarians vs Rule-of-law-itarians? I don’t know. Just don’t mention fascism, because that could never happen here.

 

*Tawdry reasons such as a congressman accepting campaign donations from military/industrial interests, etc.