Hello anesthesia enthusiasts, and welcome to
season three of Style Points. I'm not sure what
that means, other than this being the third year
of me recording the podcast. However, I feel
that calling it a season lends the podcast a
certain sense of gravitas. I'm your host, John
Crow. Today, we're going to discuss long distance
running and its physiologic implications for
anesthesiology with CRNA Jordan Crouch. Before
I let him run away with things, though, I'm going
to hand it over to my co -host, Nate Moore, to
introduce this month's RSI, which of course stands
for Resident Selected Information. Thank you,
John. I get to introduce Dr. Wes Young, formerly
a PA working in a cardiac ICU before he went
to med school and joined us in anesthesia, making
him especially qualified to give his RSI on hemodynamic
management. We think his insights are so valuable
that the chair of our department, Dr. Stuart
Birch, is currently sitting stool in his spine
case so that Wes can be with us. Welcome, Wes.
Hello, my name is Wesley Young. I'm one of the
CA1s at the University of Cincinnati, and I'm
going to talk to you about pressors in the operating
room. There are hemodynamic effects and common
uses. But before diving into the drugs and their
mechanism of action, I think it's important to
review some cardiovascular physiology. Our oxygen
delivery system can be broken down into our macrocirculation,
which we often refer to as like blood pressure,
heart rate. cardiac output and SVR. But then
we also have the microcirculation, which represents
the flow required to deliver adequate amounts
of oxygen to a particular organ. And this is
what we really care about. Some organs are great
at auto -regulation, meaning that they can maintain
flow over a wide range of blood pressures, and
others struggle a little bit in the department,
kind of like the kidneys. But they all, to a
certain extent, have the ability to have their
arterioles vasodilate or vasoconstrict depending
on local meters, like PO2, potassium, lactic
acid, etc., in order to regulate the flow. So
from a big picture, our body creates a pressure
gradient using cardiac output and changes in
the resistance provided by arterioles to increase
or decrease flow to our organs, which means we
can quickly shift blood to our quadriceps when
running a marathon or our intestines when eating
a delicious burger. The problem is that in the
OR, we have departed from normal physiology and
thrown in drugs that cause venous and arterial
dilation. Patients bleed, they have inappropriate
inflammatory cascades, and we often switch them
from negative pressure to positive pressure ventilation.
One last thing. Hypotension is the primary reason
for using vasopressors, but we can't forget that
even though our blood pressure is the driving
factor for flow, it's generated through a cardiac
output and systemic vascular resistance, either
of which could be the problem. The primary receptors
that mediate an increase in blood pressure are
typically the alpha -1 adrenergic receptor. We
also have our V1 receptor, and then we also have
the beta -1 adrenergic receptor that increases
cardiac output and heart rates. The first vasopressin
that we oftentimes use in the operating room
is called norepinephrine. It's a potent agonist
of the alpha -1 adrenate receptor, and that causes
vasoconstriction. And then there's also some
modest beta -1 adrenate activity, which helps
maintain cardiac output and doesn't have much
effect on the heart rate. We typically give this
in bolus dosing of around 8 to 16 mics. Phenylephrine,
on the other hand, is a selective alpha -1 adrenergic
agonist. It particularly leads to arterial and
venous vasoconstruction and has very little effect
on cardiac output. We typically give both doses
of around 100 mics. Ephedrine acts a little bit
differently. It indirectly stimulates the release
of endogenous norepinephrine, and has some direct
effect by binding to alpha -1 and beta -1 receptors,
but that effect isn't as pronounced. You can
see an increase in heart rate and some cardiac
output, as well as your increase in vascular
tone. We can give it intravenously through bolus
dolcing around 5 to 10 milligrams, and then we
can also use it as an IM injection around 20.
25 milligrams. Epinephrine is a non -selective
adrenergic agonist. At low doses, it causes a
beta -1 effect, mostly by increasing heart rate
and contractility. And at higher doses, it leads
to alpha -1 vasoconstriction. We typically give
bolus doses around 10 mics. Dopamine is kind
of a dirty drug that we used to use back in the
day, but it causes so many tachyarrhythmias that
we've kind of fallen out of favor. Vasopressin,
on the other hand, is a non -catecholamine vasopressor.
that acts on the V1 receptor on vascular smooth
muscle, and that causes vasoconstriction that
way. We usually give it in one to two units at
a time. So as a general rule, norepinephrine
is the most balanced vasopressor that generates
a nice rise in blood pressure without sacrificing
too much on your cardiac output. It's usually
the first -line pressor for the majority of the
shock states, and you can rarely go wrong by
giving norepinephrine. Phenylephrine is a great
drug. We've been giving it for years in the operating
room. It's a good option for the majority of
our hypotension that's related to anesthesia.
You know, a lot of our drugs cause low SVR, maybe
decreased venous tone as well, and that can be
quickly counteracted by the phenylephrine. like
pure alpha -1 agonism. So we'll see a rise in
SVR that way. But then you also have some venous
vasoconstriction, which kind of increases venous
return. We have to be careful with phenylephrine,
though. It does have a reflexive bradycardia
that we can see pretty profoundly in the operating
room. The increase in SVR also can decrease cardiac
output. So it's something to be avoided in patients
who have heart failure or severe pulmonary hypertension.
Epinephrine we use in the operating room as well.
It increases more of your cardiac output as well
as SVR. And you'll notice a nice rise in your
heart rate when you use it in the operating room.
You should be careful by not giving it too much
because it does cause some tachyarrhythmias.
Vasopressin used to be a drug that we use in
our ACLS algorithm all the time. It's a useful
adjunct to increase vascular tone. And there
is a theoretical benefit that we can increase
SVR without really affecting your pulmonary vascular
resistance. And so sometimes we'll try and use
vasopressin more in patients who have severe
pulmonary hypertension as opposed to other pressors.
And then finally, we have ephedrine. And like
we said earlier, this is the one that mostly
relies on endogenous catecholamines. And it can
be given IM, which gives it kind of a longer
acting range. And it's useful in our OB population
who oftentimes have hypotension from either the
epidural causing the sympathectomy. and it will
slowly wear off as the epidural wears off as
well. It's simply not recommended in patients
who are critically ill because they likely have
depleted catecholamine stores and therefore wouldn't
have much effect on their blood pressure. I hope
this quick review on vasopressors was helpful
and hopefully next time in the operating room
you can choose the best drug for your patient.
My athletics started in football, then to a 5K,
then to Ironman. into endurance running. I feel
like 5k to Ironman is maybe a little bit of a
jump there. Yeah, it was a progressive process.
It's kind of like a draw the rest of the owl
situation. Okay, Jordan, thanks for joining us.
Yeah, thanks for having me. Absolutely. Jordan,
before we... get started I'd love it if you'd
tell our audience a little bit about yourself
and your training all that sort of thing I've
been a nurse anesthetist for five years I trained
at UC and my athletics background is I played
football for a while and after football really
wanted to stay in shape and keep exercising but
Wasn't really interested in going to the gym
anymore. And I think football kind of made weightlifting
feel like a job. And for whatever reason, I just
kind of got burnt out on that. And I think you
see that both ways. Some runners gravitate towards
weightlifting after, you know, after their collegiate
careers. But yeah, so I took up running and I
started off with a 5K and then gradually. Kept
growing my running volume to some longer endurance
and then eventually into Ironman distance What
what is Ironman distance Ironman distance? It's
like 140 like point six miles and it involves
a 2 .4 mile swim 112 mile bike ride and then
a marathon so It's an all day event and it's
a lot of endurance and I really like that. But
there's I think there's parts of Ironman that
you gravitate towards more like you really like
swimming or you really like biking or like running.
And I really fell in love with the running part
of it the most. So I tend to gravitate towards
that afterwards. One of the reasons why I wanted
to have you on the podcast is because I've heard
you. talk about your running experience before
and i found it super interesting um you have
run i think probably more distance than maybe
the rest of the department combined i would say
is there anyone else in the department that runs
anywhere close to as much as you that's a good
question i don't know i i have heard there might
be somebody who's Trying to do like all the marathons
and all the states or something or all the all
the big marathons I'm not sure but every now
and then people you know when they hear you run
though Though it like mentioned somebody else
that also runs and it's hard to keep them all
straight But yeah, it's a lot of it's a lot of
running. It's a lot of miles. So I think the
my weekly volume I try to keep around 50 to 70
miles a week at least and then you kind of go
up or down from there depending on You know races
or what you have going on Excellent. So how do
you fit in 50 to 70 miles per week? How does
that look in your life? Well, I'm very lucky
that I live close enough that I can run to work.
So, you know, that's about six miles there. See,
that's just right out for me, because if you
said the same for me, if I said I live six miles
from work, that would exclude me from running
from work. Yeah, yeah, yeah. I mean. So it actually
it's only so it's six miles total, but it's like
three here, three home. Yeah, that's a little
bit. It's not as much. Yeah. But I think that
that's easy because, you know, after work or
before work, if you want to add a little distance,
you know, it's very easy to just keep going and
get like the training plan done or whatever you
have for that day. And it's honestly, it's a
great stress relief after work to. you know,
be able to go outside and move around. You kind
of learn to value the nice weather, you know,
after you have some bad weather. So it works
out really well for me. I know not everybody
has that luxury, you know, if you live, you know,
10, 15 miles out, but finding a way to make it
work is key. Well, let me back up for a second.
I want to ask the same question that I like to
ask everybody. If you could invite anyone over
in the world for dinner, could be somebody from
the past or even from fiction, who would you
invite over? That's a good question. I think
right now, just on top of my mind, is this character
called, his name's Gary Cantrell, and he goes
by the alias Lazarus Lake. recently featured
in a book i'm reading it just came out uh it's
a really good book but the book's called the
endurance artist and um gary cantrell he's um
credited for creating a lot of the race formats
and endurance running and he's designed a lot
of the racing styles that we that we use in an
ultra running um including the backyard race
it's a Last man standing race where you will
run 4 .1 miles every hour on the hour until there's
one person left standing. So he has these really
unorthodox or unique racing designs. And he also
is the guy behind the Barkley marathons. And
the Barkley Marathons have a pretty famous documentary
about them that made it really popular. But just
to give you an idea, the race is so difficult,
like very few people have ever finished it. I
think it's been going, you know, I'm not really
sure on the exact year, but around the 1980s,
it's been going on like that long. And, you know,
there's only been a handful of people that's
ever successfully completed it. So he really
threads the needle on. making a race that's just
difficult that it's possible to do but like very
few people can actually do it and i i think it's
interesting the book actually made him even more
interesting to me because you learn a lot more
about him and now i have more questions or more
things i want to like ask him if i could so that's
who i'd pick to have dinner with if i could i
don't know That person would want to have dinner.
They'd want to maybe go on a jog with you. Yeah,
that's right, yeah. Okay, you have sort of a
unique perspective as both an ultramarathon runner,
really, and as a practitioner of anesthesiology.
Tell me about how those things intersect. How
does it influence how you think about endurance
and physiology when you're thinking about your
training as a CRNA? and how it applies to running
these enormous distances? I think the right amount
of training and knowledge about the body allows
people to go a lot farther than what they think
is possible. And I guess that kind of comes across
in anesthesia in the sense that the body is not
really a machine. A lot of people think that
You're going to wear your joints out. But the
thing with, you know, machines is that they can't
heal themselves or they can't really adapt, you
know. So, you know, if you need new car tires,
you just go buy new car tires. They don't really
heal themselves or they don't really adjust the
amount you're driving. So one of the things,
you know, from the health care background or
from anesthesia is that our bodies are way more
incredible than what we give them credit for.
They're unique to machines in the sense that,
you know, you can train and build up your physiology.
And with through like, you know, consistent training,
you can really allow yourself to go farther than
what you think is possible. That's really interesting.
I think that in anesthesia a lot, we see people
that. are what we would consider to be surprisingly
alive, who are kind of pushing the limits of
human physiology, less because they're healthy,
but more that they are dramatically unhealthy.
So we see people who are just clinging to life
with an extremely low ejection fraction, or maybe
an extremely high BMI, things like that. But
you're talking about pushing it the other direction,
where... You're so healthy that you can overcome
some of these other things. Is that sort of what
you were saying? Oh, yeah. Yeah, I think that,
you know, the biggest thing that I notice in
ultra running is it'll show you really quickly
is consistency. You know, being consistent is
what allows for those adaptive changes. And it's
evident just in a personal level, but also just
through a lot of the training plans you see.
One of the benefits, you know, honestly, going
back to the run commuting is some would argue
that doing a double exercise during the day,
like two runs a day instead of like one long
run, is that you're actually activating a lot
of those physiological responses. You're activating
those twice. So rather than just running once
and kind of turning everything off or on and
then showing it all back off again in terms of
your exercise, doing that more frequently. could
could be beneficial so I think the consistency
of if I work you know a 12 -hour shift I'm kind
of like running every 12 hours you know if I'm
running home and then running to work and then
adding some so it really becomes like interwoven
into your life and it becomes second nature almost
like climbing a flight of stairs or walking into
work so so a lot of people are really interested
in biofeedback and People like myself, I wear
my Apple Watch or you've got Oura rings or all
these sort of things that help you measure different
physiologic parameters. And that's sort of what
we do in anesthesia as well. Is that something
that you like to take a close look at when you're
doing your runs? Is your heart rate and heart
rate variability and all those sorts of parameters?
Yeah, I do. I'm actually, as we sit here, I have
two watches on. I'm just noticing you have two
watches. Yeah, that's kind of a leading question,
I think. But yeah, it's like, you know, I do
have two watches on. So I wear the Apple Watch
while I'm at work. It connects nicely too. the
iPhone and messages, but I like to wear the running
watch at the same time because it's tracking
my recovery and a lot of the other health metrics
that you get from wearing it for extended periods
of time, like when you sleep or while you're
moving or at rest throughout the day. So even
though I'm not exercising, it's still collecting
some data that gives me information on my recovery.
How do you track your recovery? That's really
interesting. Yeah, it's mostly like heart rate
variability is a common tool. And these things
fall in and out of favor all the time. But I
mostly like to do like the sleep score. And,
you know, I like to trend these things because
I think that, you know, like an anesthesia, trending
is always a little bit more evident than just
any single number by itself. So I kind of just
hop on the trends of heart rate variability,
looking at my resting heart rate. really tell,
like, for instance, yesterday, I ran, I ran 20
miles yesterday. And this morning, on my way
to work, as I ran in here for this podcast, my
heart rate was quite a bit higher. And that just
kind of shows that I had a big effort yesterday.
So you can kind of tell, you know, like, based
on how your heart rate responds from the previous
day, how how difficult that exercise was for
you. The issue with heart rate specifically is
that It's not as much as we love numbers and
anesthesia. It's not always the greatest insight
into your efforts. Why not? Well, I think it's
usually it can be very jumpy and it can be affected
by a lot of things. And again, in anesthesia,
that's one of the things we notice is that when
we like a number, you can realize that that number
can be affected by. you know, surgical stimulation.
It can be affected by epinephrine injection.
It can be affected by all kinds of different
things. So depending on what's happening, you
know, there's a number of explanations for it.
So a lot of people like to lean towards this
scale that they create called the rate of perceived
exertion. And it's a lot of times it's abbreviated
RPE. So using the rate of perceived exertion,
you kind of come up with a scale in your own
mind. And you give yourself a score, like how
difficult is this run for me right now? Is that
what pops up on my Apple Watch after I work out
and it says, how difficult do you think that
this was? Yeah, that's exactly it. Yeah, it's
kind of getting that in your mind. So it's able
to maybe help you plan your training from there.
So if that workout was really difficult, it might
suggest an easier exercise the next day. But
it's good to kind of be in tune with that a lot
of times. The biggest thing that I think happens
is as an ultra runner, if you're really good
and consistent in your training, the thing that
tends to throw a wrench in the works is when
you have to start tapering to go into a race
because that's when your consistency fluctuates
a lot. And by tapering, I mean you start to decrease
your weekly miles and you kind of rest yourself
leading up to a big event. That big event when
it starts and sometimes because of the rest you've
taken your heart rate is like all over the place
It'll shoot way up and you're not even running
that hard, but your heart rates really high It'll
also be very erratic. So if you stop it'll it'll
come way back down And then if you start again,
it'll shoot back up or if you start going up
hilly terrains so That's where the rate of perceived
exertion comes in because a lot of times you
won't feel like you're working very hard at all.
It's really just a physiological adjustment to
maybe drinking a ton of fluids, eating a huge
meal the day before, and also just taking that
week off. It's just your body's kind of getting
set back into what you're about to do. And it
could also just be race anxiety, you know. So
what is your resting heart rate? My resting heart
rate. So. When I'm at sleep, it's occasionally
dipped into the 30s, which people love to hear
about. You know, they like to think that, you
know, my heart's beating it like once every two
seconds. You know, I don't know. It's some people
that causes anxiety. But yeah, it's most of the
time it's in the 40s or 50s. You know, I would
say if you were to look at your resting heart
rate, like if you're like throughout the day,
if you're sitting, it trends more towards like
the mid to high 50s. So a lot of people, when
they see a heart rate of 50 on an anesthesia
monitor, start to feel a little bit anxious because
they think, oh no, the heart's slowing down and
I must give glycopyrrolate to speed the heart
rate back up. And what I will typically tell
the newer practitioners who might want to treat
a heart rate of 49 or 50 is I will point to my
heart rate trend on my watch and say, Well, my
heart rate was 48 last night while I was sleeping.
Please don't sneak into my house and give me
glycopyrrolate. I don't need that to keep me
alive. That's right, yeah. Yeah, they are asleep,
yeah. And a lot of times when we're noticing
that, it's, you know, in this phase between like
after we've put them to sleep and before the
surgery starts. They're truly just laying there,
right? Like they're not even having surgery yet.
Their rate of perceived exertion is very low.
Yeah, very, very low. It's like they're in the
deepest sleep they've ever been in technically,
you know. So, yeah. That is a very interesting
point. I try to remind myself of that too because
it's very different when you see things like
that. You cycle up blood pressure and you go,
okay, it's asymptomatic bradycardia. They're
totally fine. There's no reason to really be
that worried about this. So when you do endurance
training, it changes your heart rate and your
stroke volume, things like that. Can you talk
a little bit about that? Yeah. So what you'll
generally see as you start to exercise is, you
know, they always talk about this left ventricular
left ventricle dilation that you get and you
get like a slightly increased amount of muscle
on your left ventricle that will, you know, increase
your stroke volume to help you meet the demands
that your body's asking for. And I think, you
know, that's why the consistency is so important.
You have to activate these things very consistently
over a long period of time. To get all the adaptions
that you that you're looking for to to reach
your potential and. The heart rate for me with
consistency and, you know, it wasn't with like
very hard runs all the time or anything. You
know, extra crazy. It was really just getting
outside and moving consistently, consistently.
My heart rate started to trend down where I noticed,
you know, after a couple of weeks or months.
At the same. running pace my heart rate was much
much lower and much comfortable much more comfortable
um i think a lot of people start off running
too hard or too fast for themselves and uh i
learned early on that every training session
doesn't have to be like the hardest training
session you've ever done so i you know i definitely
started off as like uh they call it like you
know the the workout hero or the training hero
where you're like trying to like break records
in your training every day. And a lot of that's
just carry over from my football experience where,
you know, it might be motivational to do that
if you're like lifting weights and you're really
trying to, you know, throw heavy weight around
and things like that. But I think for running,
it's really just about like, like a consistency
that you can maintain and sustain and going too
hard every day is not sustainable. It's just,
it's going to lead to injury and, and, some you
know other complications and also burnout are
you shooting for a particular heart rate when
you're running yeah for me everybody has a little
bit different that you can calculate there's
ways to calculating your heart rate zones um
you know the oldest one that we hear about is
220 minus your age and uh you can kind of calculate
it from instead of the generic 220 you can kind
of calculate it from a maximum heart rate where
you give your hardest effort See how high your,
you know, heart rate will get and then kind of
calculate some heart rate zones from there. It
gets a little bit more complicated because with
your training, you can actually dilate out these
heart rate zones. Heart rate zones being like,
like zone one would be, you know, like you're
almost at rest or not really doing like very
difficult activity at all. And zone two would
be like a very comfortable. slightly elevated
heart rate so for me i think it's around like
120 to 140 but you can actually extend these
out so that they're they're wider to some extent
you know depending on how your training is focused
so you know track athletes might have a very
like wider upper range or a very like you know
steep upper range where they can go into like
very high heart rates because that's what they're
pushing a lot of the time so when you're Prepping
for a really long run, it strikes me as some
of the same prep that we would do for a really
long anesthetic. There's things that you have
to plan on in terms of hydration and sodium and
all those sorts of things. Can you talk a little
bit about the physiology of what it takes to
plan for a really long run and what you do to
prepare? Yeah, I think that is something that
is kind of... overlaps a lot with ultra running
is like the planning component um it's tough
because as a as the runner and you're the only
one that's being affected by your own decisions
so it's very easy just to to go out the door
without without doing the planning you need to
do um but you learn quickly that it's important
to take the second to think like do i need gloves
before i do this because you know cold hands
can really just kind of ruin the whole run if
your hands are cold the whole time uh but Yeah,
you know, there are a lot of things I basically
for myself personally, I'll take, you know, maybe
some electrolyte drink with me. If not, then
I kind of just rely on gas stations, which I
think is kind of fun. Like you just run to like
some unknown area that you haven't been to before,
haven't been to in a long time and pop into a
gas station, get a snack, get a drink, and then
you just kind of keep the run going. I usually
do that if I'm doing like 20 plus miles, I'll
do that around like mile 13. And I'll grab a
drink, grab some food, and then just go back
out and finish the next, you know, seven plus
miles. The nice thing about that as well is that
it kind of is a little bit of a stomach training.
And it's very similar to a race in which as I'm
running, I will, you know, stop and get all this
food and, you know, eat maybe like a snack and
then. drink a bunch of fluid and then uh start
running again and that's kind of very similar
to like a race where you might come up to an
aid station you're going to eat and drink a lot
and then you're going to start running again
and it kind of helps your body get used to that
feeling if you're running one of your big 100
mile races or something like that how much fluid
do you need to support yourself in that sort
of environment is it just purely based on thirst
or is there calculations that you have to do?
How does that work? Yeah, I kind of wish it was
purely based on thirst because there would be
a lot less calculation needed. But unfortunately,
I think when you're setting a goal, you know,
goal -based fluid replacement, you know, when
you're setting a goal to it, that's when it kind
of becomes dangerous because you can override
a lot of those mechanisms because, you know,
you've calculated that you do, in fact, need
a certain amount. And you're going to override
like I'm not going to wait till I'm thirsty.
It's an ultra running. It may be too late, you
know, to start eating when you're hungry. Like
it's very hard to to meet the demands. You know,
once once you're already getting like signals
really firing that, oh, you're thirsty, you need
water. And it's like it's hard to replenish and
keep it going for an extended period of time.
It might not be a bad option to drink to thirst
in a shorter event like a 5K or even the Camarathon.
But. I think a shorter event, like a marathon,
like a marathon, just because you on that. Yeah,
I think, I think because, you know, the consequences,
well, marathons can be long, you know, depending
on the speed and things like that. The consequences
don't play out over like. over the entire night
you know like a 24 -hour race if you make a mistake
you have to deal with the consequences until
like from 7 p .m to 7 a .m so it can be it can
be a long haul but you know back to the question
about the electrolyte goals and then the fluid
replacement so I tend to the best way to kind
of come up with a plan for fluid replacement
that I've come across is You weigh yourself before
an exercise without clothes or anything as a
variable. You go out into the heat and run for
about an hour and come back and weigh yourself
again. That will essentially, the only thing
that will be different there is that the amount
that you sweated is gone. So any kind of sweat
loss is out of the equation now. And you'll come
up with a weight difference. You'll convert that
to liters in terms of water. Um, and you'll,
your goal would be to replace 90 to 95 % of that.
So if you lost, you know, like two liters of
sweat in an hour and like a very hot condition,
um, that's kind of on the upper, upper end of
the sweat loss. But if you were to do that, you
would aim for, you know, like 1 .8 liters of
replacement. And then is that just water that
you're replacing? Yeah. So in this equation,
it's, it's, you kind of just figure out the water.
component so it'd be like 1 .8 liters and the
most important part of this is that the amount
of electrolytes you replace is a ratio so you
don't really want to like pick like an electrolyte
like and think i'm going to take 500 milligrams
of sodium every hour that's like not what you
want to do you always want to replace electrolytes
as a ratio to water because as your water intake
changes then your electrolyte intake will change
To give you an example, one of my races, I had
a very difficult time with electrolytes. My goal
was to kind of just drink this amount of water,
take this amount of electrolytes every hour.
What I ended up finding out was that I had severely
low sodium at one point because I had taken in
about three gallons of water and very, very little
electrolyte because the hourly intake electrolytes
I had calculated seemed okay. Until you add in
the three gallons of water. It was very imbalanced.
You know, it's very water heavy So I kind of
went through the cascade of every symptom of
low sodium that you could have, you know Let's
go over hyponatremia. Let's go back to internal
medicine days. Yeah. Yeah, so step by step, you
know, I I Didn't really notice the first couple
signs, you know It was hard it was eventually
became hard to to want to take in anything um
so i started having like like lack of thirst
and then kind of lethargic a little bit and i
felt like my performance was lacking like in
terms of like the run and i was having a hard
time like running um and that's one of the first
things you'll see with dehydration in a sense
is that you're having a difficulty like maintaining
the performance you were you were before But
eventually it got to the point that I was kind
of confused and a little bit delirious. But again,
you're running a race at the sun setting is starting
to get dark outside. So you're thinking like,
you know, it's just all part of the race. What
I ended up realizing as things progressed down
were that I began to lose fine motor function,
which is one of the very final signs of hyponatremia.
So, yeah. Talk about what that means. What did
you notice? Yeah. Again, this was all of these
things. I think at the time I wasn't the best
person to step back and analyze this at the time
because I was, in fact, the person who was being
affected by it. But I remember as the sun went
down, I felt like my hands were cold. And in
reality, it was just that they weren't working
because of hyponatremia. Because I think it was
like 78 degrees outside. I remember I was having
a hard time like turning my headlight on, things
like that. And I felt like I needed gloves, you
know, even though it was 78 degrees out. And
I just I couldn't put the pieces together. I
wasn't the best. At the time, I was the best
person to help myself. But thankfully, the crew
that I had, you know, in my last ounce of self
-preservation, they gave me a sodium tablet.
And even though I was being pretty uncooperative
at the time, I guess, I think they were able
to get me to take this sodium tablet. And I kind
of laid down for a second and eventually came
to and felt 100 times better just from like getting
sodium in my system. So, you know, you live and
you learn. And that's something like I didn't
always try to connect dots, you know, from my
anesthesia experience. But, you know, that. You
know, these ratios that we use in terms of fluid
replacement, like having a balanced crystalloid
solution, you know, in a sense, that's kind of
what you need to do for fluid replacement. Another
area this came up in is we did the analysis on
whole blood replacement, you know, rather than
reconstituting whole blood, you know, making
whole blood through multiple units of packed
reds and FFP and cryo and all these components.
we're trialing this whole blood, uh, and, and
traumas. And it's very similar to that. It's
like, it's much easier to do, um, like the, you
know, like the solution that's like a, you know,
electrolyte drink or electrolyte mix versus like,
I'm going to drink a bunch of water and then
I'm going to take a bunch of sodium and then
I'm going to drink a bunch more water. And then
I'm going to take a bunch of sodium. It's like,
you know, having a more stable, smooth, uh, hydration
plan is, is much, much easier to maintain and,
and, uh, easier to control. So some of the different
races that you've run or been adjacent to deal
with some pretty extreme temperatures too, right?
Can you talk a little bit about that? Yeah. So
I, you know, the crazy thing about, you know,
performing outside is temperature starts to affect
you. And this is from, you know, research, but
the heat. In particular, heat starts to affect
you as little as 45 degrees Fahrenheit. So if
it's over 45, you're dealing with heat. And even
though that's typically a cold temperature, that's
where it begins to affect your performance. So
heat training has become really popular lately.
It's shown to increase red blood cell mass and
kind of help you adapt to... oxygen carrying
capacity and and uh heat um during your exercise
or during your races so one of the races i was
a part of um was you know one of the hardest
ultra marathons in the world it's uh called the
bad water 135 um i was able to go out and crew
and pace uh my friend uh harvey lewis He was
doing it for the 14th time, which is absolutely
incredible to think. Somebody's done that race
14 times. He's very skilled and talented. We
went out there this past summer, and again, of
course, it's in Death Valley. The race is in
the summer, so they really leaned into the heat
component of this race. How hot is it there?
race is going on yeah so uh there's nobody ever
really confirms anything but there's rumors that
it's the 135 miles and it's the bad water 135
because it's been 135 degrees out there before
so there's like some kind of like link to that
um i think uh when we were out there it was a
it was a chilly year you know it was kind of
cool that year and it was like 120. You know,
it's not too hot, you know, just 120 degrees.
Did you wear a jacket? Yeah. Yeah, I wore a jacket
and I wore gloves also. No, the the the interesting
thing. So the the heat in Death Valley, a lot
of people were saying that like, oh, well, Death
Valley, it's a dry heat. I always before this
was leading up to the race and I kept thinking.
yeah it's dry heat but it's still feel the fuel
like temperature is still 125 you know like it's
still like if it's 125 degrees it's 125 degrees
that's something i can set my oven to yeah exactly
so yeah um it certainly was hot but i will i
can you know give a testament to the heat training
i think that the sauna really helped and again
it's it with sauna specifically the saw in a
training plan they actually had one from the
race you know it's the first race i've ever been
a part of that had requirements for crews and
pacers where they actually sent us a a guide
and kind of showed us the how to you know prepare
yourself for the heat out there as hard as the
race is they have a really good safety record
and they're really well organized and making
sure everybody is safe during the event and the
like just like ultra running the sauna plan is
mostly about consistency it's about exposing
yourself to heat very consistently so that you
get these adaptive changes and what you'll find
is that throughout these sauna sessions after
a week or so you tend to get way more comfortable
and you'll surpass thresholds where you would
previously feel like you really had to get out
of the sauna You'll kind of meet that mark and
be like, oh, I remember this part. You know,
I remember when that used to be very, very difficult.
And now I'm like, you know, zoned out completely.
I'm not even really focused on my effort in here
up until five minutes after that now. So what
happens with your GI system when you're on these
long runs? Do you find that you still need to
go to the bathroom the same amount or? How does
that work? Are you finding yourself hungry? What
do you eat? Yeah, you know, I'm lucky that I
don't I haven't really had any stomach problems.
So I guess I'm lucky in that sense. And I generally
I find it easiest in races to eat things that
are familiar to you. A lot of people, you know,
you could try these like the sports sugar supplements
like the. goo like the gels and things like that
these uh they have like sachets of um different
components of it's like maltodextrin powder with
water and some fructose um they're essentially
simple sugars that are easy easy to digest as
the thought and uh they work in you know a more
timely matter once you consume them they'll get
into your bloodstream quicker um but i you know
i find for these longer events one of the enjoyable
parts is coming up to an aid station with a like
wide variety of snacks. And you can kind of just
look at the layout and just find something that
looks good to you and eat it. And I think that
that for a lot of people starting out is a really
good way of going about nutrition because in
the end, the goal is just to keep eating and
not to be dependent on something that you're
like very tired of eating. And you can get palate
fatigue with some of those gels where. You just
can't stand to eat another one. And that's not
a situation you want to be in because ultimately
in these events, your body needs fuel. So just
finding fuel any way you can get it, you know,
whether it's something sweet or salty, just finding
something that sounds good to you at the moment
and keeping your palate moving. In a really long
race, I imagine you've been doing essentially
the same thing for a very long time. How do you
manage the mental fatigue and stress of being
in these extremely long events? Yeah, you know,
that's a really good question. I think that,
you know, with training, to be honest, the difficulty
and the time component, it actually just extends
everything out further. So in a sense, you're
chasing the dragon of that difficulty even further
every time. For instance, the last race I did,
I had one of the best, you know, trainings like
blocks going into it. I had really great training.
I had a lot of really great guidance from friends
and things. And I remember going into that race.
I actually didn't feel any difficulty until around
like mile 70. Like it felt very comfortable.
And I, you know, I just felt. You know, to be
honest, I didn't have any issues. Like the weather
was like relatively good. It was kind of hot
during the day, but I had done a lot of heat
training. So overall, you know, I felt very,
very good up through mile 70. And when it gets
difficult, I really just more appreciate it.
I find a way to appreciate it because you had
to run 70 miles for it to get difficult, you
know. And that's something you've worked really
hard to feel. I don't really dread it at all.
I think that like, you know, you find out how
deep your well is in a sense whenever you get
to that moment and you get some difficulty from
it. The component of like kind of like getting
stressed out during a race is a lot of times
if the weather changes, you know, if you're dealing
with things that you kind of didn't anticipate
during the race, like. You think the race is
going to be hard, but when it starts thunderstorming
and things get really muddy, there are ways to
deal with, you know, stress or like, you know,
some like negative mental aspects during a race.
One of the big things with that that I learned
from Harvey Lewis is to kind of reframe or just
really focus on what you can control. I think
that that, again, has a lot of overlap with anesthesia.
You know, if you get into a critical situation,
we have like protocols already in place. We have
a plan of how we're going to do it. And you really
just focus on that. You're not really focused
on, you know, something not going well. If all
else fails, do chest compressions. Exactly. Yeah,
there's always a plan B, C, and D. So that's...
that's really helpful in that sense is I really
just focused on what I can control. The one race
I did that had a lot of mud and, you know, as
a runner, that's one of the most dreaded things
because you do a lot of training and you do a
lot of running. And then if you get to a race
and you have to walk through mud for like eight
hours, it's like, it's like, you know, you start
to really think like, I didn't come out here
to walk through mud for eight hours, but I just
kind of. You know, you can reframe it and, you
know, think, well, you know, it's muddy for everybody
and it's everybody's wet and it's raining on
everybody. So it's not a problem that's unique
to you. And with the with the mud, you know,
if you just keep going, it's it gets better.
And that race in particular, it rained again
and there's like puddles that formed. And the
puddles actually helped you clean the mud off
of yourself a little bit. And it actually made
the mud less sticky. So as much as everybody
was frustrated about the additional rain, it
actually made the course better, you know, in
a sense. So, yeah, I just try to focus on what
I can control. And in that sense, like, am I
getting blisters because of this mud? Like, maybe
I need to do extra management with my feet or
my shoes to help manage it. Or maybe I need to,
you know. change, you know, clothes a little
bit more often or prepare, you know, try to wipe
some of the mud off your legs if you're starting
to get like, you know, friction or rubbing around
like your shorts and stuff like that. So what's
the next big race that you're planning to do?
So the plan right now, the very next one is going
to be in just about a month, I think. So in December,
there's a race called the Dreadmill. And it's
a treadmill race, so it's – I'm sure everybody's
done this, but – You're going to have to explain
what a treadmill race is. Yeah, so it's a race
that's 48 hours on a treadmill, and the goal
is just to go as far as you can. So it's pretty
easy. I'm pretty sure the Geneva Convention has
outlawed what you're talking about. Yeah, it
might be a war crime. You're right. Yeah. So,
yeah, the Dreadmill, I did it last year. It's
actually a really fun race because there's people
who you know that might not run or might not
run your pace. But they can come over and hang
out with you the whole time you're doing it,
you know, and you can be right next to them.
So it adds like a lot of layers. Like that's
the fun thing about these races is that there's
different formats and there's always like a different
layer that makes it a little bit more interesting
or a little bit more fun. While like, you know,
a lot of these races are very solo, you know,
the community around them is really good. So
almost every race I've made. two to three friends
that I talk to you regularly, you know, and like
the network has grown so much just because of
the community and I think people knowing like
the consistency and the training it takes you
kind of find solidarity in that and My one of
my first races I met you know a friend that I
now use their treadmill for this treadmill race
and We kind of do it together and it's it's been
a lot of fun so Do you have any rituals that
you will do before a race or after a race? Yeah,
I think the lead up to a race can be it's different
for everybody. But a lot of people mentioned
if they really taper their training, it's strange,
but you can kind of get a little bit irritable
from not running as much. It's just a strange
phenomena. I think it's like. Maybe you're not
getting the outlet or maybe you have like this
extra energy that's kind of given off an irritability
or, you know, it's really hard to describe. I
don't find that I'm like super irritable, but
I do feel like I have like some like energy that
I can't really do anything with going into a
race. So in addition to that, I also cut my caffeine.
So I've completely stopped caffeine the week
of a race. to kind of make myself more sensitive
to it. And basically going into a race that last
day or so of prep can be very, uh, like stressful
and frustrating, I guess, because you're doing
a lot of stuff for the race, but it's not running,
you know, and it can be a little hectic sometimes
where you kind of just want to be done with all
that background stuff and just start running
in the race. So I think the biggest thing that
I do is I, plan in that I'm going to have everything
done by a certain time and truly have like a
window of time where I do like nothing where
I can just relax and not have to do anything
else for the race. And just that way I'm able
to say everything is done. Like everything's
been checked and double checked and I have everything
I need. And most importantly, my ritual is try
to go to bed early. A lot of the races, either
the commute to the race or the race itself will
start early in the morning. And, you know, if
you're doing a race that's going to go for 24
hours or more, you know, sometimes 30 plus hours
or sometimes days, then you really want to start
that off with a good night of sleep, you know.
But I think that that as a ritual is giving me,
you know, I think success so far in terms of
feeling tired during a race. So lastly, what
style points or points of personal preference?
have helped you both in and out of the operating
room or both on and off of the race course? I
think being consistent in some kind of exercise
is super important. You know, I kind of talked
when I first did my introduction, I talked about
this circuitous path to ultra running. And, you
know, when I look back at that, I realized that
it's. really just like a legacy of just like
physical activity. Like, you know, that's kind
of what it's chalked up to. It's not really,
you know, it's just my personal story of just
being physically active. And it doesn't have
to be, you know, one specific thing. You can
always like change out of, you know, different
things that you're into at the time. But in the
end, it's all physical activity. And I think
that having some component of that, even if it
changes over the years, is super important to
your professional life. a great work -life balance
it's a great like stress reliever um it um yeah
it keeps you healthy you know like weight -bearing
exercise and just you know it helps you age better
and um you have a much better uh quality of life
for much longer that's really neat i appreciate
that and i have one last question for you do
you feel like you're running towards something
or away from something oh man that's a good question
it depends you know i yes you asked me a question
earlier about uh the competition during or about
the the last part of a race in the last 80 miles
or when you get to mile 80 of a race and uh you
know a big part of that is the competition at
that point you know in the beginning of 100 mile
race mile one for me personally i'm not super
concerned about the competition or really looking
at the competition, but around mile 80, it can
be a big motivator. And in those cases, you do
feel like you're both chasing somebody and you're
running away from somebody. So that's kind of
the fun of the race is that like, there's a lot
of camaraderie, like your competition will be
like offering you water, like offering you help,
um, at the same time as like you're racing them.
And it's, it's, you know, that's, that's all
part of like the, the fun culture of, of ultra
marathons. Jordan, thank you so much for joining
us. Yeah. Thanks for having me. Thanks for joining
us for yet another episode of the award -winning
style points podcast. What award you ask? That
would be the award for the best anesthesiology
themed long form interview style podcast at the
university of Cincinnati, which I am proud to
have won and also conceived of. Congratulations.
If you would like to help us win additional awards,
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.com. Well, we have reached the end of the marathon,
everyone. Take a deep breath. Open your eyes.
We're all done.