Understanding Hyponatremia Key to EMS Providers at the Country’s Largest Bicycle Race

Nicholas Defouw, "Dr. Nick," talks with Rob Stork from Topeka who made it 26 miles into the race. Stork was experiencing abdominal pain and had difficulty breathing. Hotter'N Hell Hundred. Wichita Falls, Texas. Aug. 25, 2012. (Photo/Bradley Wilson)

Even at the starting line, it was evident that providing “prehospital” healthcare is important to the organizers of the Hotter ‘N Hell Hundred race in Wichita Falls, Texas, the largest single-day 100-mile bicycle ride in the United States. “One of our primary goals,” Executive Director Ben “Chip” Filer said to the nearly 14,000 riders, “is to ensure that everyone who comes to the race goes home vertical.”

To accomplish this goal, organizers recruited more than 1,000 medical volunteers at 15 stops along the 100-mile route. Filer assured the racers that the volunteer medical staff–consisting of doctors, EMS personnel, nurses and others–”can do a lot of stuff out there that would normally [require a trip to] the hospital.”

The organizers’ efforts paid off. Although the medical staff saw some 900 people throughout the day, only 14 were transported to local emergency departments.

The Wind
For most riders, it wasn’t the heat that caused problems, it was the wind. Even at 6 a.m., before the sun had risen or the race had begun, Gene Johnston, a first-time rider in the 100-mile race, predicted, “The wind is going to be the biggest problem if it keeps up today.”

He was right.

By mid-morning, David Melton, a biker brought to the medical tent for treatment of a minor injury noted, “The wind is so brutal.”

Kim Stringfellow, a nurse working at the last rest stop before the finish line, said, “The temperature is milder than in past years, but the wind is worse. [The bikers] are coming in more tired.”

At the same rest stop, Trey Mial, a biker from Houston riding in the 50-mile race route, said, “The heat’s not too bad. The wind’s been kicking everyone’s butt, especially in the last stretch.”

And out at the remote rest stops, medical staff volunteers turned the wind to their advantage. Twelve-year volunteer Lee Ackley, a physician assistant from Iowa Park, Texas, said, “The wind is bad for bikers, but it keeps us cool. “¦ It’s good for us.”

Learning Opportunities

Medics from AMR help Rob Stork get on the stretcher and into the ambulance. Hotter’N Hell Hundred. Wichita Falls, Texas. Aug. 25, 2012. (Photo/Bradley Wilson)

Despite the expected high temperatures and this year’s strong winds, the medical team was prepared. The on-site staff successfully provided routine medical care, including suturing wounds, IV fluid therapy and massages for muscle cramps. Staff and ambulances from American Medical Response (AMR), who provide daily EMS transport and prehospital assistance for citizens of Wichita Falls, as well as Air Evac Lifeteam helicopters and staff, also contracted by the city, were both on-hand to assist with any life-threatening injuries.

Keith Williamson, university physician at Midwestern State University and medical director for the race, noted that the race is a tremendous learning opportunity for the medical staff volunteers. “You see a bunch of new things that aren’t in your diagnostic lexicon,” he said, referring to illnesses and injuries that many of the volunteers might have learned about in school and might, theoretically, know how to diagnose and treat but have probably not actually seen in the field.

Jim Barbee, medical doctor and program director of the sports medicine fellowship since 2002, said, “[The medical staff volunteers] learn how to manage a major medical treatment unit at a large public event. They love it. It’s one of the few times you can work the devil out of residents and they love it.”

Jason Mogonye, a medical doctor and clinical faculty member at John Peter Smith Hospital, also wanted the sports medicine fellows and other medical staff volunteers to learn in this unique environment. “I want them to know how to handle athletes who have been competing for a very long period of time and [to learn about the] trauma that happens [during] a bicycle race,” he said.

Barbee also noted that the tent could have been staffed primarily with paramedics; however, “the public expectation is for doctors,” he noted. “We’re helping [the volunteering doctors] learn how to help us,” he said.

The Heat
Temperatures on this year’s race day averaged 95ËšF–109ËšF was the high temperature one year–and Filer told riders they were “lucky” this year because it “cooled down” to a high of 96ËšF, 10 degrees lower than in 2011.

Before the race began, Nicholas DeFouw, a medical doctor and participant in the sports medicine fellowship program at John Peter Smith Hospital in Forth Worth, predicted that he and the other five doctors working in the medical tent at the start/finish line would see a lot of what they usually see: cramping, broken bones, dislocations, lacerations and, of course, heat-related conditions. According to DeFouw, many of the riders are just not acclimated to competing in extreme heat and, like others, in daily life they are acclimated to an air-conditioned environment. So when they spend five hours exercising in extreme heat, their bodies simply cannot adapt quickly enough.

The expected bruises, broken bones and scrapes did indeed occupy most of the medical staff’s time on race day, but Williamson and the other volunteers coordinating and planning the events medical care spend most of their pre-race planning time discussing how to treat heat-related injuries.

Kenny Hoffman, operations supervisor for AMR, said he paid attention to the weather forecast a couple weeks before the race. “I kept waiting to see what the temperature was going to be. It actually cooled off. We were thankful for that.”

Hoffman said AMR, which has been working the race since at least 1991, typically staffs two extra ambulances on race day to help with call volume, but notes that the biggest problem for his staff are the bikers themselves. “Bikers don’t move out of the way,” Hoffman said. “They hear lights and sirens and they just say, “˜whatever.’ Getting to a rider that is sick or hurt, that is a real problem.”

From the emergency management point of view, Henderson said he does not really make special plans due to the heat, even though last year was the hottest event on record and the first time the race was black-flagged, with riders forced to stop mid-race. “Heat is a given,” Henderson said. “I am more concerned with other threats such as the possibility of lightning and storms. I also plan for large wildfires in the counties and city. We are always vigilant on watching [the Wichita Falls] Multi-Purpose Event Center for suspicious activity that people might want to cause chaos to a large event. Those are more pressing to me than heat.”

Because heat emergencies can be life-threatening and acute, Hoffman said he works closely with the dispatchers and race medical staff. “We determine the best care that can be given to the patient. We look at who can get there the fastest. It works great,” he said.

Ackley said few people get to see the massive numbers of heat-related injuries that they can see at this race. “Here you get to see 20 to 30 at a time,” he said.

“˜Water Intoxication’
In particular, he said medical staff members are on the lookout not only for dehydration but also for hyponatremia, also called “water intoxication,” which results from drinking excess amounts of plain water, causing the blood serum level of sodium to go down.

Hyponatremia is becoming more prevalent as participation in endurance races such as the Hotter ‘N Hell Hundred increases, particularly by inexperienced athletes not acclimated to racing in extreme heat. Because the body loses sodium when it sweats, athletes have to consume additional sodium and water to replace what they have lost. Consuming water alone decreases the concentration of sodium in the blood and can result in nausea and vomiting, confusion, headache, paresthesia, puffiness and seizures.

As part of the medical protocols for the race, Williamson has a specific protocol for hyponatremia. In contrast to the protocol for dehydration and overheated riders, both of which calls for IV therapy, “hyponatremia can be worsened by hydration,” Williamson states in the IV protocol.

Williamson recalled a rider who a number of years ago got him interested in hyponatremia. That specific rider came into the medical tent and said he “just needed to rest.” Shortly thereafter, he had a seizure. He said it was fortunate that the medical staff at the race that year was “on the cutting edge” and knew how to treat the rider based on reading the research in exercise-associated hyponatremia.

Prior to learning how to treat hyponatremia, medical staff volunteers were putting about four riders per year in intensive care. “We haven’t had to put anyone in intensive care since,” he said.

What is Defouw’s solution to overhydration without adjusting electrolytes in the body? “Pickles,” he said. “The riders worry a lot about hydration so they drink a lot of water and even Gatorade. They rehydrate but sweat the salt of out their body. Clinically, racers say they feel better after they eat pickles.” Indeed, huge jars of pickles are amongst the supplies at the medical tent.

Crossing the Finish Line

Almost as if he had gotten the message before the race, John Battaliou, a rider from Oklahoma City, sat at the starting line waiting for the sun to rise and for the blast of the canon that begins the race. With two bottles of green juice strapped to his bike–pickle juice and lemon-lime Gatorade–he was prepared. He said his goal was not only to eliminate the need for medical attention but to eliminate his need to make any rest stops.

“No rest stops,” Battaliou insists. “Hell no. Rest stops are for sissies,” he said, stating that he expected to be done in less than five hours. His best so far was finishing at 4:37. “You have to be prepared and you have to know your limits.”

This was a mantra that medical staff volunteers found themselves saying to riders and visitors over and over during the day, saving almost all of them from a trip to the hospital.

Bradley Wilson, PhD, has been an EMT-I since 1991 after first volunteering in Texas and then, for the past 10 years, for Cary area EMS in North Carolina. He is currently an assistant professor at Midwestern State University in Wichita Falls, Texas

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