Ironman (DNF) Dispatch: The Medical Postmortem, and Tips for Beginners

Hello blog friends. That was a bit of a hiatus there, wasn’t it? And I don’t even have the excuse of Ironman training anymore. I’ve been filling my hours not with biking, riding, swimming, or running, but with being blissfully……lazy. Skipping a workout because there wasn’t time and I wasn’t going to get out of bed before dawn to get it done. Sleeping in on Saturday mornings?! What frightening new world is this?!

A while back, I met with my endocrinologist for the first time since the Ironman. In fact, it was the first time I had seen her in nearly nine months. Hey, she’s popular and my A1C has been okay. We debriefed on various races and talked for a long time about my race experience at IMWI. I’m sharing here in hopes of providing insight both for diabetic athletes and aspiring Ironmen without diabetes.

Like I said previously, I had a lot of little problems pile up over the course of the day that eventually left me too weak to continue. Primary among those were issues with fluctuating blood sugar and nausea. My BG was 336 before the swim and 66 in transition. (It had never gone low during the swim before.) Along the bike, I went from feeling “meh” about my fuel, to feeling queasy, to feeling like vomiting, to involuntarily gagging and spitting out food when I tried the tiniest nibble. My bike pace was slower than predicted, given my training rides, and I spent most of the time worried about making the bike cutoff. As the hours passed, the calories dwindled and I felt terrible unless I was on a flat stretch. Which, given the Wisconsin bike course…..one of the hilliest in the nation….was NEVER. I pulled over at mile 85, on the second of the Three Bitches.

My endo and I reviewed the morning blood sugar and insulin management strategy. I had woken up somewhere in the 200s and given a small correction plus breakfast bolus, as previously rehearsed. I ate a Clif Bar, banana, and peanut butter like normal. I started drinking my Generation Ucan about an hour before the start of the swim, maybe a little more than an hour. As I was dropping off my transition bags, I checked my BG one last time since I’d be leaving my meter and insulin in there for the bike. That was when I got the 336, a little after 6 AM.

Decision time: DO I GIVE MYSELF A SHOT? Consider this a Top 5 list of why I said yes.

  1. My BG was way too high to compete effectively.
  2. I still had half my Generation Ucan left to drink, about 15-20 g carb.
  3. It had been over 90 minutes since my breakfast, so while the BG was inflated from the sports drink, it’s not like the majority of my breakfast carbs were still in my system.
  4. I had butterflies in my stomach and I knew that the mass start swim would be an adrenaline rush, driving up blood sugar even more.
  5. In all my past races my blood sugar was quite high coming out of the swim– at least the mid 200s, if not 300s. My blood sugars on the bike trended high too.

I ended up injecting 4 units- 2 for the remaining Ucan and 2 for a partial correction. (Normal correction of a number in the 330s for me would be 6-7 units.)

Endo nodded along as I explained all this. Then she pointed out that while my BG stayed high on my shorter swims and workouts, perhaps the extra activity of a long swim pulled the glycogen into my muscles, plunging my blood sugar into hypoglycemia territory. She also speculated on the location of the shot (I had long forgotten where I injected by that point), saying that a shot anywhere near my arm or leg muscles would have greater effectiveness than an abdomen injection. While that’s a 5-to-1.5 ratio of evidence favoring more insulin instead of less at the start…..it makes more sense than the Diabetes Fairy siphoning glucose directly from my bloodstream and giving me the random low.

 photo ugly fairy.jpg
I imagine the Diabetes Fairy would look like this: unattractive and prone to making you feel like you’ve been hit with a large mallet. Image via Zazzle

So my body was recovering from the low. Adrenaline and cortisol surged to dump more glucose into the system (this is why people in hypoglycemia experience rapid heartbeat, nervousness, sweating, shakes, etc). Blood and oxygen needed to get to the brain, the body’s hungriest consumer of glucose, in order to equalize.

But at the same time, I was still exercising—pretty vigorously, thanks to those hills. So blood needed to travel to my legs to power the bike. And of course, during long distance exercise, blood ALSO needs to go to the stomach to digest fuel.

So this physiological stress spurred what my endo called the vagal response. Blood vessels dilate and blood pools in the lower extremities, depriving the heart and brain of blood. The heart slows down, and in some cases blood flow to the brain drops so much that a person faints (vasovagal syncope). “Vagal” refers to the vagus nerve, which controls breathing, heart rate, sweating, and food emptying from the stomach. Basically all the parasympathetic actions that are necessary for successful endurance racing.

 photo Vagus nerve Grays Anatomy.png
From Gray’s Anatomy, and Wikipedia

This is bad. Heart rate and cardiac output need to INCREASE to support exercise. But they needed to DECREASE to support bloodflow equilibrium. I could feel my heart beating rapidly. In fact, I was distressed at how slow I was going for how fast my heart rate was. The anxiety about falling below cutoff speeds likely created a vicious feedback loop of more adrenaline and cortisol, further raising my heart rate. I tried to focus on riding within my limits and staying calm, but one can’t quell fear entirely when 13.4 mph is required to continue competition and one is going at 13.6…13.2…12.7….12.5…12.1…..

I learned all of this in the past few weeks from my endo and Dr. Google, so I don’t know anything for sure. But I’m pretty confident that my body entered some kind of physiological impasse. I had so many presyncopal symptoms: nausea, lightheadedness, weakness, pale skin. The progressive inability to take in food was my body’s way of preserving bloodflow efficiency however it could. Nothing could be diverted to my stomach while my heart, brain, and legs were competing for resources. So I gagged on anything I tried putting in there.

This was also the body’s way of saying, “Hey! Stop what you’re doing and let me straighten this out!” Had I not stopped, it appears that I would have either:

  1. Gotten pulled over by race officials far from my family for inability to make the cutoff
  2. Or gotten taken away by medics for eventually fainting on the course

So I found my family on the side of the road. I cried (or more accurately, did an ugly face crumple because I was dehydrated). Then I hobbled to the car and we drove to a Mexican restaurant, where my body was still so out of whack that it took me more than an hour to force down one glass of water and some plain tortilla chips.

ON TOP OF ALL THAT…in January, I tried to give blood and was rejected because my iron was low. I’ve had anemia on and off for years, so it didn’t surprise me. But if I was anemic during the race– likely, since exercise depletes iron stores– then that messed up my performance even more. Iron is key to getting oxygen into the cells, so low iron means increased blood lactate levels and cardiac output (since the heart has to pump harder to get oxygen circulating).

So that’s the story, as best as we can tell. Surprise low blood sugar plus anemia triggers vagal response, irrevocably impairing performance.

I guess you could say that if I didn’t have diabetes, I could have finished the Ironman.

But if I didn’t have diabetes…..would I have even started in the first place?

That’s an interesting question. It requires re-imagining a dozen years of my life in which I don’t have an urgent motivation to care for my health. Years that I don’t decide to chase big physical challenges because I want to see what my body can do after grappling with the daily fallout of what it can’t do. They would be years in which I likely would not have found a community of diabetic athletes and been inspired by their accomplishments….and I doubt I would have thought I was inspiring others if I tried the same.

Besides, Jeff is the one who convinced me to go for IMWI in the first place, and I never would have met such a BAD-mofo if I didn’t have “D” myself.

But diabetes wasn’t the ONLY thing that drew me to the endurance sport prize that is Ironman. And it’s immature to blame diabetes for the DNF, without examination of my own training and self-management. I can’t fix my busted pancreas (and believe me, if I could– it would make all this a lot easier), but what is within my control?

All these months since the race have helped me to distill the answer to that question. Behold:

SIX TIPS TO FINISH YOUR FIRST IRONMAN, UNLIKE ME!

1. Work on the foundation. I understood the risk of tackling a full Ironman without much triathlon experience. Years of general endurance experience, sure, but not much by way of triathlon or ultra long course work. It was a gamble that I lost this time around, and I could have increased my odds if I devoted more time to working up to it. Of course, then I wouldn’t have started in IMWI 2015. One of my ROI teammates, Anne Marie, went this route. After reflecting on her 2015 season, she decided to drop out of IMWI and target Ironman Mont Tremblant 11 months later in order to race her best Ironman.

Working on the foundation also means the foundation of the race itself, which is the bike. I biked a LOT and improved my skills a great deal, but I didn’t have enough speed and skill to conquer both a difficult course and a bad day.

2.  Hire a coach. Another decision that I knew was risky. Financially, it was just not in the cards last year. But it could have made a difference in targeting my weaknesses and formulating an adequate plan B on the days when workouts were derailed due to travel, unfortunate blood sugars, etc. For a less experienced triathelete tackling a big goal, I would have saved the money to make sure I could invest in expert planning and guidance. Again, that would have meant not participating in IMWI 2015. Hence my decision to rely on a plan I bought without individual coaching, online resources, and the advice of many friends and family who had done Ironman before. I think individual coaching is worth the investment for something as giant as this.

 photo Ironman GIF.gif
Be like this guy! Source: Giphy

3. Practice every piece, even if you think you don’t need it. Perhaps I could have nipped that BG dip in the bud if I had done a full 2.4 mile swim followed by a long ride in training. I did little swimming in the run-up to IMWI because it seemed like an inefficient allocation of time. I’m an average swimmer and comfortable in open water. Hours spent practicing swimming would have yielded a 10-15 minute swim time improvement, whereas devoting extra hours to bike practice can make you tremendously faster on race day.

4. Strive to overcome logistical hurdles. How would I even have accomplished a long swim-bike brick? The outdoor pool doesn’t open early on weekend mornings, and the gym pool is a joke. I did not feel comfortable leaving my precious (and expensive) bike on a rack in crime-ridden Coney Island while I swam in the ocean. And I didn’t have a car to lock the bike in. The lack of car affected the quality of my long rides, given that I had to spend time cycling through the city to get out on roads like 9W or the trailways in Westchester. I usually took the train back home from the GW Bridge so that I wouldn’t add even more junk miles (and time) to my total. Car rental or Zipcar was another additional expense. Next time, I would try harder (or budget additional bucks) to get around these issues.

And logistical hurdles goes for workouts during busy times, too. I was much more disciplined than normal about fitting them in– you have to be! However, I could have always done better. Woken up earlier, gotten out the door faster, planned the weekly schedule more tightly. A Type B Ironman-to-be like me needs to get REAL anal to make it work.

5. Get a complete physical. Oh, you guys. I have no excuse for this except for….distraction, I guess. (Or not being anal enough, see point 4). My primary care doc left the practice before I started training. I wasn’t injured (thank goodness). But I could have treated that anemia if I had gotten a checkup and bloodwork. Making sure you’re healthy means you’re that much stronger on race day. And female endurance athletes– particularly runners– are QUITE prone to low iron levels.

6. Have more fun! I was part of team Riding on Insulin, but with all of us so far-flung, I couldn’t ever work out with them. And while training alone has many perks (greater flexibility, ability to sing stupid pop songs or curse on bike rides without judgment), it sure can make things a grind. If I do this again, I’ll link up with a local group. You spend a whole lot of hours training for an Ironman….might as well make them go by quicker with camaraderie, jokes, and friendship. And given the uncertainty of race day– from bike malfunctions to bad weather to, yes, diabetes– the process needs to be worth it if your race ends up going to hell.

 

Not a week has gone by in the past eight months that I don’t think about Ironman Wisconsin or feel sad that I couldn’t finish it. I hope there’s a next time, but it won’t be any time soon.

I am, however, proud of the accomplishments that I did achieve. Most importantly, the money that was raised for Type 1 diabetic youth through Riding on Insulin. We made a great impact on those kids and families. There’s no medal or bragging rights in it, but that’s pretty cool for me. Thank you to everyone who contributed!

 photo ROI with Mike Reilly.jpg
The team with Mike Reilly. His words may not have come true that weekend, but I’m honored to be part of the group.

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4 thoughts on “Ironman (DNF) Dispatch: The Medical Postmortem, and Tips for Beginners

  1. So not true. There is a pancake flat stretch of road after Whitte Road going into Cross Plaines. It’s almost a mile long…and you do it twice! So, there really is only 110 hilly miles on the bike course. ;-)

    Someone pointed out to me that the elevation gain in Wisconsin T2 in greater then the entire elevation gain on the IM Maryland bike (24 feet).

    Wisconsin is brutal. I experience much of the same stomach turmoil and I was convinced that officials would not let me leave T2 (so weak and dehydrated…stomach rejected even sips of water for most of the bike), and I did not have diabetes to contend with. I am in awe of what you did accomplish considering your blood sugar roller coaster. I am sure that you have learned much from your experience and will be successful if you try it again. But perhaps you got what you needed from the experience you had. I knew when I signed up that I would only take one shot at Ironman. Finish, DNF, bad weather, shortened course, canceled event or whatever else happened, I would not try again (turned out to be a perfect day with perfect conditions). There were too many variables out of my control, so I stopped worrying. About them. I simply came to one basic truth…that victory was crossing the starting line…knowing that I did the training, that I earned my spot and that I truly belonged there. If I could say that when the cannon fired, then I had already succeeded. The rest of the day would be a celebration of the journey that got me to the start. It is the training and the mindset that forges an Ironman. You don’t need Mike Riley telling you. That is a formality. The mindset is there. The dedication, the work ethic, the drive.

    Yeah, you are an Ironman in my book.

    Thank you for sharing.

  2. Wow! Thank you for sharing your story. I have done a Sprint tri (I know so short compared to an IM) and my sister (not diabetic) is doing an Ironman in October so the triathlon story with diabetes is so interesting to me. I probably won’t ever do an ironman but it was definitely interesting to hear about your story. I’m so glad you were OK. I didn’t even think about the absorbency in the arm/leg difference between the abdomen..so interesting!

  3. You are back, yay! This is great info for anyone, diabetes or not. Also, I still think you are a real badass. And huge THANK YOU for fundraising for ROI. My kids went to snowboarding camp in January and it was awesome. I’m fundraising for them now, but just running.

  4. Wow, this was really fascinating. I mean, it totally sucked and I hate that it happened to you. But the explanation and how our bodies work is totally fascinating. I hope you know what a hero you are!!

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