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Wed 20th Nov 2019
The Kona Medic's experience
Posted by: Editor
Posted on: Monday 28th October 2013

Tags  Kona  |  Kona 2013  |  Medical Tent  |  Tamsin Lewis

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British long distance professional Tamsin Lewis (, was in Kona this year for the Ironman World Championships. You won't have seen her in the GB results however, as Tamsin wasn't racing - she was there with her medical hat (or should that me coat...?) on, once again working on the event as part of the medical team, and also attending the annual Sports Medicine conference in the lead up to the race.

We've seen plenty of coverage of the racing action and results over the past two weeks, but it seemed like a great idea to get an insight into what goes on 'behind-the-scenes', and with conditions so tough and competition so fierce, the medical support requirements can be crucial. So, I asked Tamsin if she would give us an insight into the medical support at the Ironman World Champs, what it involves and what she learned from it.

Every year in Kona they hold a Sports Medicine conference in the week leading up to the race. Some superb speakers come along, and this year included Prof Greg Whyte (@gpwhyte), Asker Jeukendrup - Professor of Sports Science (@Jeukendrup), Doug Hiller (Medical Committee ITU) and some other leading key research specialists in nutrition. Some of the data presented truly is fascinating and I also question its application to athletes, so as to maximise my learning.

I am a big sponge when it come to absorbing knowledge relevant to the sport. I am less interested in the orthopaedic/sports injury side of sports medicine and more in the physiological side including nutrient and hormonal deficiencies and of course having trained as a psychiatrist, the psychological side of the sport also fascinates me.

Kona 2013 - the medic

I love to observe athletes at Kona, from an objective standpoint. I am not racing so there is no competitive instinct, just watching how different athletes prepare, the varying levels of anxiety and interactions with others, and of course on race day watching the tactics used and observing the form of the athletes.

I noticed specifically that Rinny (Mirinda Carfrae) back with coach Siri Lindley this year looked stronger again having looked like she'd lost too much weight in 2012. Caroline Steffen too has lost a lot of weight this year, testament to the number of races she has done and perhaps media pressure and she told me post race that this affected her strength. A lesson here - striving to be uber lean and dropping weight does not directly translate to performance gains. If you go into a race like Kona depleted from a nutrient standpoint it will come back to bite you. Listening to a talk at the conference they presented data which shows that pre-race carbohydrate loading is feared by many (especially women), as they appear to gain weight…this is mostly in the form of water (glycogen attracts water for storage) and is actually a good thing as this raised total body water can be seen as a camel's hump to be drawn upon during the race.

The medical team at Kona has some superb physicians whom Ironman are lucky enough to have volunteer for the event.

In the morning of the race I help with some of the pre-race weigh-ins and then am on the pier with a walky-talky observing for any swim casualties. Last year we had a few athletes pulled out - two with hypothermia (yes, getting too cold - they were in the water 30mins before start time and then were amongst the slower swimmers). Also a couple of cases of SIPE (swelling in the lungs) which can be fatal have presented.

Kona 2013 - the medic

When the athletes are out on the bike, I help prep the tent with IV's and other logistics and then I head out onto the run course on my bike supporting friends and again checking for any casualties. Unfortunately I was at the wrong end of the course when Jodie (Swallow) collapsed and I heard that she was waiting over half an hour for an ambulance, which is suboptimal, and the medical team have taken this into account when planning volunteer placement on the course next year.

Once the top athletes have finished I either go straight into the tent or Triage at the Finish Line. This year I did a bit of both, going into the tent a bit later as I was watching Catherine Faux finish biking behind her.. again observing and in awe!

Kona 2013 - the medic ©Richard Melik

We had a very sad case this year where a girl was about to finish sub-10 but she couldn't even crawl to the finish line - her brain literally overheating and she was unable to co-ordinate any movement at all. We carried her over the line and soon after she started having seizures - her temperature was over 40°C. We cooled her as best we could but she was very unwell and was transferred immediately to the hospital where she spent three days recovering.

Kona 2013 - the medic ©Richard MelikMany of the athletes in the tent were overheated and dehydrated - muscle damage measured by a blood test was much higher in these people and no doubt they will recover far slower than those who maintained their core temperatures better. When overheated there is less blood in the gut so less fluid and calories are absorbed. The blood is diverted to the skin so as to facilitate sweating and radiant heat loss. Some athletes develop actual damage to their bowel as a result of this (most famously Chris Legh had to undergo surgery to remove dead bowel).

I learnt that many people simply do not understand or practice their nutrition enough. Taking on too much sports drink on the course actually dilutes your own body's electrolytes and gives false signals to the kidneys and the brain about self-regulation. as you may have read in Tim Noakes "Waterlogged" - this is actually more dangerous than dehydration.

A race nutrition plan for Ironman that works in temperate conditions like Canada for example would need to be adjusted for a hot and humid race like Kona. Less blood in the gut increases likelihood of GI distress as does dehydration itself. You can train the gut like the muscles to acclimatise by training with race nutrition in the race conditions, but this takes time.

Pre race sodium loading seems to help some as it increases total body water which the body then draws on during the race.

I would like to study the helmets used by the athletes who are admitted to the tent because I saw a fair number of Kask Bambinos with visors being worn and can imagine there would be some serious overheating there. Overheating too would increase perceived exertion and accumulation of waste products forcing a pace drop - unless you can somehow suppress your central governor (as some manage to) for a time.

One bug bear was that this year the 'criteria' for admission to the med tent seemed far stricter. I was monitoring those coming across the line and directing some to medical, but in the times that I wasn't there some managed to bypass the tent. Every hour I checked the post race area and brought in about eight people who had been missed and were either collapsed or delirious.

There were equipment constraints in the tent which meant that IV bags and medications were not being distributed as much as previously. We were told only to test the blood of the more serious admissions as testing equipment was low and there was no urine testing at all.

For an organisation like Ironman to scrimp on this kind of equipment just furthers my opinion that concerns for their athletes is not a priority. How much would it have cost them to put some inflatable ice baths in the finish area to assist recovery and reduce hyperthermia? Next year there will be some private funding to do some research into markers of heart damage in med tent admissions which I will be involved in setting up.

So in summary. the key things we saw in medical:

  • Hyperthermia
  • Dehydration
  • Hyponatraemia
  • Muscle cramping
  • Cardiac arrhythmias - mainly atrial fibrillation

Kona 2013

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