Western States Tips, or go and get your buckle

With all the applicants and the apparently imminent demise of the 2-time loser rule, you may only get one shot at Western States, so here are some tips on getting that silver buckle.
I made it in 2007 after just breaking 28 hours 4 years earlier (race report and pictures)

Pre Race
1. Get in. This is rapidly becoming be the hardest part
2. Pick a year with little snow and good weather. 2007 was great for this. If global warming is real I think we’ll see less snow, but hotter temperatures. Of course the temperature on 1 day in June is going to be more variable that the snow over an entire winter
3. Train hard. I think you know this one
4. Get the rest of your life in order. Unless you are independently wealthy without family. training is going to impact the rest of your life. I let some things at work go and assured my family I’d have more time after the race. I also made the commitment to get up at 4:30 on Tuesdays and Thursdays to run 11 miles before getting home to get my kids up from school. I also got up that early or earlier on Saturdays when I had long runs, so I wasn’t gone the whole day. Your situation will vary but it is important to realize the effect training will have on the rest of your life.
5. Don’t overemphasize total miles. I think this is not the best metric for your training. Think about what runs you want to get in (long runs; back to backs, hill work; speed, etc) and focus on that, not the totals. Last year’s winner , Hal Koerner noted he only ran about 70 miles per week as opposed to 100 previously. I only ran about 50 miles per week on average, but that was usually in 4 runs/week with a good long run every 2-3 weeks. I cross-trained the equivalent of another 20-30 miles a week
6. Don’t overrace. Koerner also noted this was different about his training for 2007. I didn’t run a single race in 2007 before WS. I would have done some if they were convenient, but for me it was better to do long runs at home rather than travel to and from a race.
7. Take care of yourself. As you ramp up your training you have to be very careful about fueling and hydrating. As an example, if I am not training hard and I run 7 miles on a Tuesday morning, my next workout might not be until Wednesday or even Thursday so I might shower and get my kids up and dressed before I eat or drank, maybe 45 minutes, knowing I have lots of time to catch up on fueling and hydration. 2 months out from WS, I might run 11.5 on Tuesday morning, then lift and do a walking workout on the treadmill after work and a rowing workout Wednesday morning. In that case, I MUST drink and eat right after I finish my run. Then during the day, I have to keep up on hydration and make sure to have a snack before going to the gym. Similarly, I can’t afford to stay up watching TV or whatever; I need to make sure to get my rest. As training picks up your margin of error decreases.
8. Keep up with little things like stretching and ankle strength.
9. Be strong. I really felt strength work helped me, particularly late in the race. The ups and (especially) downs will be very tough on your quads and it is hard for running alone to prepare you for that, especially if you don’t regularly train on tough trail There are a lot of different opinions about what the best strength work for ultrarunners is, and I’m not sure it is the same for everyone. I’m big and come from a background of lots of lifting, so for me, 2 about half hour sessions a week focusing on lunges, pull-ups and dips was perfect, but other stuff might work just as well. The last few months before WS I cut back to 20 minute sessions and focused on maintaining my strength. Some people like to cut back to once a week, but I get too sore that way.
10. Have at least one cross-training activity. It is good to be able to get a good workout on days you want to stay off your legs, and you WILL have some minor injuries that will keep you from running. Having a cross-training activity will allow you to still workout while you recover. If you haven’t doing a specific activity I think it is hard to jump in and get a really good workout. I rowed in college and have a good rowing machine so that was good for me (and helped my quads) but I don’t think the actual activity is as important as having something you can do besides running.
The Course
11. Be ready for a tough course. If you just read the ULTRA list, you get the impression this is a pretty easy course with a few tough climbs. This is not true, unless you run primarily on technical single track. The first 1/2 of the race is at altitude and this will affect your performance. There are several very difficult climbs (the start, to Robinson Flat in the new/old course, and of course the canyons). Parts of the trail are moderately technical and even the dirt road parts mostly are rocky enough you need to pay attention. I saw one race report where they said that the course just never lets up, and I think that is apt. It isn’t at super high altitude, isn’t super-technical, etc, but it is NOT easy. If you don’t believe me, ask Greg Crowther.
12. Know the course. If possible go to the training weekend or do runs on the course. I never actually did this, but I thought the course knowledge I gained the first time I ran really helped me the second time. If nothing else, go to the course description meeting a few days before the race. It helps to know, for example, that after you top out Emigrant Pass you hit some single-track, and that it is a steady uphill to the aid station at Ford’s Bar. I think the benefit is both physical and mental
13. Be a good walker. Unless you are going to finish in the top 10 or so you are going to walk a lot on the uphills. I estimate I walked 40-50% of the course and still got under 24 hours. If you are going to spend that much time walking you need to practice it. I like practicing walking on a treadmill so I can get long, sustained climbs. My two favorite workouts were an hour at 15% grade and 4.0mph and successive miles at 15%/4.0 mph, 12%/4.3mph, 9%/4.6mph, 6%/5.0mph and 3%/5.5mph. If you lived where there were long hills, you could do some good hikes. If you think you don’t need to train to walk well, read this account of a winner of Angeles Crest where he talks about hikes as part of his training
14. Be a good downhill runner. It is a net downhill course and if you can run fast on the downs you can gain a lot of time. None of it is horribly technical but there are rocks and roots and some of the steeper downs can make you nervous (think Last Chance to Deadwood Canyon). See Crowther again.

RACE DAY
15. Don’t go out too fast. The desire to get ahead of 24 hour pace is strong, but you have to be careful with the altitude early in the race. Let the race come to you.
16. Don’t obsess about the 24 hour pace, especially early on. The times they post at aid stations (and are on the website) are really rough approximations. For example, between Duncan Canyon and Last Change is 5 trail miles. Not hard trail, but not all downhill and not super easy. Following the 24 hour “pace” you have to run this in 45 minutes . It is easy to get too worried about losing or gaining 5 or 10 minutes between stations. Focus more on running well but staying within yourself. There is time to be made up late in the course if you are running well. Also, note that 24 hour pace accounts for you slowing down as the race goes on, it gets dark, etc as well as for variations in course diffculty.
17. Get in and out of aid stations. My pacer said after the race I actually took more than 24 hours to run the course, but spent negative 28 minutes in aid stations! Get what you need but don’t waste time. If you have a crew and a chair it is easy to sit an extra five minutes, but you may wish you had those 5 minutes back at the end. If you don’t believe me check out Matt Carpenter's account of his record run at Leadville:

In reviewing tapes of previous LT100s (the 1994 race with Herrera and Trason is an epic on par with any Hollywood production) I was amazed by the amount of time runners of all abilities spent in the aid stations. Bottom line, 5 minutes at an aid station means having to run 30 seconds a mile faster over the next 10 miles just to break even. Impossible!

As someone once said about WS “I had a chair to sit in, to; at the FINISH”
18. You’ll hear “the race starts at Foresthill” and in many ways it is true. If you look at the historical splits, lots of sub-24 finishers make up time from there to the river, and the course gets much easier after Green Gate. You have to get to Foresthill in good shape.
19. Use the light you have. My pacer, Tom Watson, told me coming out of Foresthill that we had 2 1/2 hours of daylight left and we should make the best use of it. As it gets dark you will slow down, so really push that last few hours.
Mental tips
20. Go for it. This may be your only shot and 24 hours isn’t very long. Don’t give up on your race mid-way because you are tired or hurting. Back off a little and
21. Have confidence. My biggest worry was that at some point I just wouldn’t be able to tough it out: I’d be on or near 24 hour pace but wouldn’t be able to push through to the finish. As it went, I remember distinctly getting to Foresthill at 6:35 or so and thinking “I’ll do whatever it takes to make it.” All those early mornings and long runs are strengthening your mentally as well as physically.

Now go and get your buckle.

Pittsburgh Indoor Sprints Rowing Race Report

I led for only 200 meters, but fortunately they were the last 200.

I put down 6:50 as my estimated time 3 weeks ago, but after some short workouts at higher rates (strokes per minute) I figured I could go significantly under that, maybe even 6:40 if everything went perfectly. The 6:50 left me as second seed of 11 racers. The guy in first had put down 6:47 and won the race last year in about that time.

I got to the race just about 45 minutes prior to the race, expecting maybe a few dozen people. Instead there were several hundred, including a lot of rowers from local colleges.
I started my warmup about 30 minutes prior to race time, as we were supposed to be ready 10-15 minutes early.

10 minutes prior to race time we got to get on the race ergs. It was weird as we were facing the bleachers with lots of people just 10 feet away. The others were continuing to warm up, but I stuck to my plan and just waited for the start once I got the drag factor set. Kipp, the guy seeded first is actually smaller than me. I figured if it was close, I should be able to use my size and strength to beat him over the last 300 meters or so. The monitors were cool. In addition to the usual info about meters left and pace, it showed what place you were in, and how far you were behind the leader as well as the guys immediately ahead of and behind you.

Soon enough we started. Searching the web there seemed to be 2 basic race strategies. One is to take a few hard strokes to get started and then immediately settle into your goal pace. The other is to use your adrenaline the first 20 strokes or so to get ahead of your goal, then settle into a pace just slightly slower than your goal and try to make up any deficit in the last few hundeed meters. I figured I’d take 3 fast strokes to get going, 10 hard strokes, then take the next 10 to settle down to 1:40-1:41 per 500 meter pace.

Apparently, there is a 3rd popular strategy, which is to go all out the first 500m and try to hold on. This turns out to be as effective in rowing as in running, which is to say not very.

I was at 1:36-1:38 my first 10 strokes then settled down to 1:40 to 1:41. My rate was only 30 strokes per minutes, a bit slower than I’d planned, but I felt strong and like I was rowing within myself so I didn’t push it (in general, rowing the same pace at a lower rate is a bit less tiring). Some guy named Storm took it out incredibly hard. By the 500 meter mark I was 29 meters (about 6 seconds) behind him and in 4th overall. Holy Cow. I had promised myself I’d row my race, so I stuck with my pace and let the race come to me. By 700 meters down, I was in 3rd, still 29 meters behind this Storm guy and 9 meters (maybe 2 seconds) behind Kip, who was seeded first. Storm all of sudden starts coming back to us, no surprise. By 1000 meters I’ve almost caught him but was still 9 meters back of Kipp. At halfway my average pace is about 1:40.6 or 3:21.2 for 1000 meters

With 900 meters to go, I decide to try and make a move. I push my rate up a bit and aim for 1:39-1:40 instead of 1:400-1:41. No dice. Kipp is tough and I’m getting nowhere. Storm has exploded (how painful must his last 1000 have been?) and I’m 20 meters or so up on 3nd. I’m thinking I’ve got second wrapped up but it isn’t looking good for winning.

But I keep pushing, and by 600m to go the lead is 8m. Not much but maybe there is a chink in his armor. I had planned to start my sprint at 600 to go, but I’ve pushed so hard already, I don’t have much more. By 500 to go though, I’m hitting 1:39s consistently and the lead is 6 or 7 meters. I’m redlining here with the rate up to 32-33 and slowly moving back. At 300 I’m 3 meters down but moving through him. The spectators realized it is a hell of a race and start to really cheer. At 200, we are even, but I’ve pushed the pace down to 1:37 and he is, in retrospect, dying. With 10 strokes to go (100 meters) I have to back off a touch (to 1:38-1:39) and my last 2 strokes are 1:40 and 1:41 as my tank is empty. But Kipp has crashed. I finish in 6:39.3, the fastest I’ve rowed since college. Kipp is like 6:42, so I put some distance up on him in the last strokes, winning by maybe 10 meters.

Oh did that hurt. I just slide up and down for 30 seconds or so as the rest of the racers finish. That may be the hardest I’ve EVER pushed myself over a shortish distance. After a minute or 2 everyone else is done and we get up to make way for the next race. After walking around for a couple minutes I have to sit down just to catch my breath. Wheww.

Epilogue: All that air going in and out of my lungs gives the sensation that you’ve burned your windpipe and lungs. I coughed up a storm the next 2 hours and am still coughing up some phlegm 12 hours later.

In retrospect, this was a fine race. I stuck with my race plan even as others went out too fast. I held my pace and managed to row through everyone for the win. The fact I tired just a wee bit at the end shows how much I’d already given. I might have gone just a bit faster if I’d taken it out faster, but given this was my first (and perhaps last) race like this, I think a bit slow was better than too fast. Just ask Storm

Western States Pictures

Thanks to Tom Watson, pacer extrordinaire, for these. If you click (or maybe double click on them) you'll see bigger versions.
This is the view from the start.
The first climb takes you up over the shoulder on the left of the mountain dead ahead (at least that is how I remember it).
When you arrive in Squaw Valley and see what this climb looks like, it tends to have a sphincter tightening effect.






Second is the plaque on a rock near the start.

Third is a picture of the start. It nicely captures the feeling you get: it's dark, there are 400 runners, lights and a huge sense of anticipation

Me at Robinson Flat, doing something


Some nice views of the high country, taken by Tom so presumably somewhere around Robinson Flat.



My ace crew (Isabel and Colin) waiting at Michigan Bluff (I think). Remember CREW = Cranky runner, endless waiting.


I even stopped for a picture (I hate to waste time in aid stations)



Tom, resting up before his big night. He looks innocent here, but there is a dark side to him! Seriously, he was invaluble in pushing me those last 38 miles.





Crossing the finish line. I love this picture as it sort of sums up how I felt at the end. I was just a small part of an enormous undertaking. I have this as the background on my desktop at work. I also like that dark sky

Getting my finishing medal from Tim Twietmeyer. This was his first "off" year after doing the race 25 consecutive times under 24 hours, including several wins. Incredible.

Getting my belt buckle (gingerly) with Adrianne in the foreground

One Hundred Miles, One (very long) Day

It used to seem to me, That my life ran on too fast
And I had to take it slowly, Just to make the good parts last
But when you’re born to run, It’s so hard to just slow down
So don’t be surprised to see me, Back in that bright part of town
-Steve Windwood

Executive summary: 23:42:06. One Hundred Miles, One Day. A dream come true. Silver Buckle. The race of a lifetime, probably. I think sub-24 at Western States is very hard and yet attainable to runners of average talent like myself. People think the course isn’t that difficult, but it features rocky trail, altitude, lots of ups and downs and heat. It is MUCH tougher than the “easier” 100s I’ve done (Umstead, Vermont and Arkansas). Those of us from the east seem to have particular difficulty with this race.

The hairs on your arm will stand up; with the terror in each sip and in each sup;
Will you partake of that last offered cup, Or fade away, into the potter’s ground?
-Johnny Cash

Prologue: I had early success in my ultra career despite what most would consider minimal mileage (I ran sub-22 hours at Umstead, my first 100, on 100-130 mile months). That came to a crashing halt my first time at Western States in 2004. The altitude did a number on me and for a while it looked like I wouldn’t even finish. I rallied as the trail dropped and finished under 28 hours. It remains the race I’m proudest of, because of how I persevered under adversity. I wanted to come back; not so much to redeem myself but to see what I could do on a good day.

I didn’t apply for 2004 because I was relocating from Boston to Pittsburgh and knew I couldn’t spare the time for the race. I lost in the lottery for 2005 and 2006, so knew I was in for 2007 (I had conveniently qualified for both the 2006 and 2007 lotteries at Arkansas Traveler in 2005). But a new problems appeared: my knee hurt whenever I ran. I had hurt it playing basketball in college and had ACL replacement in medical school. More worrisome was that they had had to remove all the cartilage on the inner part of the joint, the cartilage that serves to cushion the impact between upper and lower leg bones. I had always been careful about mileage and for many years had not run on consecutive days. But for some reason it got a lot worse all of a sudden. By October, I was fat, out-of-shape and couldn’t run at all.

I went to a local sports medicine specialist. On the way out, a colleague mentioned that he was known for not telling runners to stop running. Sounds good, I thought. He took one look at my X-ray and said “you’ve got to stop running on that knee.” Uggh. I pouted for a couple days, but my friend Dave Fish mentioned how many people he’d run with who’d been told they’d have to stop. The doc had gone on to give me some advice on what to do if I ignored his initial advice, mostly focusing on strengthening the quads and hamstrings, which had atrophied.

I decided to give it a shot. A former collegiate oarsman, I knew rowing would strengthen the quads, so I started rowing like a madman on my Concept II. I eased back into running with a few laps on a decrepit cinder track near my house. I also restarted strength work, which I had let slip. This combination worked wonders and my knee felt better. I put in >1000 miles preceding the race in 2007, rowed another 300, and did lots of uphill walking on the treadmill and strength work. I worked up to 2 difficult walking workouts (1hour at 4 miles per hour and 15% grade and successive miles at 4.0 mph/15% grade, 4.3/12%, 4.6/9%, 5.0/6% and 5.5/3%). I also built up to 2x20 dips and 2x10 pullups as well as 2x15 lunges (each leg) holding 35 lbs dumbbells in each hand.

Despite the knee issues, I started running the day after my long runs. Several times after doing 30-35 trail miles on Saturday, I’d do 10-12 miles with a running group. Having previously trained exclusively by myself, I found it much easier to get through runs on tired legs with company. On non-long run weekends, I tried to keep up with the faster runners in the group on the uphills, which helped my speed. My weight dropped from 212 in October to the 180s in June. I’d weigh in at 187, 16 lbs. lighter than 4 years previous.

My left hamstring bothered me sometimes during speed work, so I got less of that in than I’d have liked. Amazingly, I was able to back off early and not miss a ton of training, rather than trying to train through and getting really hurt. Must be the wisdom of years. My knee felt as good as it had post-surgery and it bothered me almost not-at-all the last few months.

Given my family and job responsibilities, I knew this was the best 100 mile shape I’d ever be in.

PRERACE: After attending my in-laws 50tth anniversary in Vegas the weekend prior to the race; we arrived at our condo on Monday night. We did fun stuff around the area (Donner Party museum, rafting on the Truckee, etc.). If you are ever in Reno go to Eclipse Pizza, run by my friend Dave Fish, for the best pizza and salads I’ve ever had. Get the apple goat-cheese salad. It’s awesome.

My wife commented on how relaxed I seemed. I figured I had trained as hard as I could, given my professional and personal life, so what was there to be nervous about. My ace pacer, Tom Watson, arrived Thursday night. On Friday they told us the course would be free of snow and the highs might only be in the 80s. The stars were starting to align…


“He who races the clock has an opponent who knows no casualty”

GAMEDAY: I gave my kids a kiss before I left. My daughter, usually a heavy sleeper, woke up and said “Daddy, I like the brass buckle better, because it looks likes gold!” Hmm

The hype seemed less than 4 years ago, but that was probably more me than anything external. I walked up the big hill at the start running only a few flatter sections. By the top there were lots of people both ahead of and behind me and I was about 54m, right on 24 hour time. This year I was able to run in the high country, which was beautiful with wildflowers, and snow free. I pushed a little harder than I should of, wanting not to get behind 24 hour pace. This was a mistake, but not a fatal one. The “new/old” course was much tougher and I was really feeling the altitude on the climb to Robinson Flat. I arrived there a few minutes ahead of 24 hour pace, but knew I was working too hard. I decided to forget about sub-24 and the buckle and just run comfortably. It was a great decision. From there to Last Chance I just ran along, enjoying myself out on the trail. I was keeping up on my nutrition and hydration, taking a Succeed cap every hour and a gel every 25-30 minutes.

I ran hard on the downhill (and faceplanted) out of Last Chance and then climbed steadily up to Devil’s Thumb. 4 years ago I had started to feel better in this section and passed about 20 people on both the way down and up. This year I only passed a couple, but I did it in 1:15, which is quick. As I was heading down toward the cemetery, another runner, I think Keith Straw, caught up to me. I was still just running my race, but he was confident we’d make sub-24, going on about how this was the toughest cut-off and all we had to do was keep moving. I didn’t get too caught up in it, but I started to think I had a shot. He had to stop to get a rock out of his shoe and I didn’t see him again until the end. I fell again heading down to El Dorado but had a good climb to Michigan Bluff. I saw my family there, which was nice, but didn’t spend much time in aid stations all day. At Foresthill, I saw my friend and colleague Geoff Kurland who was the M.D. at the aid staion and Dave Fish and his girlfriend, who were working, and Tom and my family as well. Still in an out in 2 minutes.

I left about 6:35; by this point I was ~25 minutes ahead of 24 hour pace and starting to believe. I told Tom to push me as hard as necessary to get there on time. This was totally unnecessary as Tom had no mercy.. The trail from Foresthill to the River is mostly downhill (but rolling) and mostly runnable, with less rocks than average for this course. Tom suggested using the remaining daylight, which I did, running a lot of the flats here. We didn’t need our lights until Ford’s Bar. The river seemed lower than 4 years ago, but was refreshing on my legs. I had fresh socks and shoes at the far side, but didn’t want to take the time to change. We were out by 10:20, forty minutes of cushion. The stretch from here to Auburn Lakes (and really Brown’s Bar) has lots of relatively flat, smooth, runnable trail, but my quads were so trashed I mostly walked the flats, but aggressively. I would shuffle the downhills (not really running, Tom would tell me, just letting gravity do some of the work). We did okay until slowing on the nasty downhill from Brown’s Bar and the subsequent climb up to Highway 49. We got there about 2:50, having lost about half our cushion, but still 20 minutes ahead of 24 hour pace and with >2 hours to go less than 7 miles. The math was definitely in my favor.

Tom “suggested” I run some of the downhill to No Hands “just to make sure.” After the 49 crossing there is about a mile mostly uphill until you turn and head down toward No Hands Bridge. At the turn there were a couple yahoos and a lot of Christmas lights to make sure you don’t miss the turn. The guys were pretty boisterous and were yelling for us “Go get your buckle” and “Silver” which fired me up. As we headed down toward No Hands there was a runner in front of me, just barely shuffling the down hills. It was almost funny how slowly he “ran.” And I couldn’t catch him. So I just shuffled along behind him. It was perhaps the ugliest running of my life; reminiscent of 8 months earlier when I had to take walking breaks on the cinder track. But run I did, and when we hit the bridge we had 80 minutes to do 3 miles and I knew I’d make it. The climb up to Auburn didn’t seem so bad and I liked the searchlights they had set up at the high school. I felt a lot better as we got closer and closer to the high school and gave Tom my pack and light before we hit the track. I have to say enjoyed running around the track knowing I’d made it and made my goal of sub-24. I’d dreamed of running around that track in the dark for 10 years and now I was finally doing it.

AFTERMATH: Boy was I tired! This was by far the hardest 24 hours of my life. I’d never run so much on tired quads or pushed so hard all day. My friend Damon Lease says that when he ran a sub-3 hour marathon he cared about his time every step of the way. I’m not sure my intensity was that high, but it was close.

But it was cold at the finish and I was worried about getting chilled. I had planned to get a massage but hadn’t really left any clothes or anything at the finish. Tom’s car was parked up above the grandstand so I had to hobble up that. A women watching commented “One last hill” as I staggered up. I laughed and said “they told me that 3 miles ago!”

We stood at the top watching the last sub-24 finishers come in. I was glad to see Keith Straw, who had gotten me fired up back at Last Chance make it in under the wire. I broke down a little as I thought of all the work I’d done, and how I’d dreamed of this. I was also a little bit down as I hadn’t really thought I ran that well. I went out too fast and didn’t finish strong. I made some mental errors like forgetting to get gels at some aid stations and not realizing I had Succeed caps and naproxen with me the last 30 miles. It seemed like a hundred people passed me in the last 20 miles.. I knew there’d be a lot of silver buckles given out with the conditions as they were, so I hadn’t worried at all about that during the race, but wished I’d run a little stronger at the end.

Tom and I drove to our hotel, which was 20 minutes away. It was a big hotel and we were the room farthest away from the entrance. My wife commented the hall must look like another 100 miles to me. I had a few blisters but I’ve had worse. But when I got in the shower, I started hyperventilating and getting dizzy so I had to sit down in the tub, no easy feat. By the time I finished the free breakfast at our hotel had started, so Tom and I went down. I ate about 4000 calories.

We slept a few hours (note to self and others: when feet are blistered post race, pulling the sheets and blankets all the way out from under the mattress makes it much more comfortable). The awards ceremony was mercifully short. Any disappointment I had felt about my race was gone by the time I hobbled up to get my buckle. It really was a dream come true. All those runners who passed me look fit! I apologized to my daughter for getting the silver one, but she replied “now you have one of each!” We ate at In and Out Burger (another 4000 calories) and headed back to the hotel for more sleep.

I took the red-eye home on Monday night and could feel my legs swelling the whole way. By midway on the flight the skin over my feet and ankles was stretched tight and I was getting a bit worried. Once I got home (and fought rush hour traffic) and put my feet up for a few hours, they got a lot better. The hyper-soreness in my quads passed in two days, although even two week later I feel the healing microtears whenever I get into or out of a chair. I strained the tendon on the front of my right calf and that took 10 days to head. I’ve done a few easy runs the last week and my cardiovascular system feels great, but my legs feel dead.

Huge thanks to Adrianne, my wife, and my kids Colin and Isabel for putting up with all the training time; to my Sunday morning running buddies for helping me make it through the back-to-backs and making me faster, especially Todd Green for inviting me and Alex Sax for organizing. The volunteers and organizers of this race are awesome. Early on I was frustrated and upon arriving at an aid station with my bottles still 1/2 full told the volunteers I didn’t need any more fluid. As I was grabbing a gel, a volunteer came up and nicely told me it was 6 miles to the next aid station and I should reconsider. I did and he nicely filled up my bottles, which were dry by the time I got to the next one. Things like that set this race apart. Above all thanks to my pacer Tom Watson. He pushed me hard, which is exactly what I needed, although I may not have appreciated it so much at the time. Maybe I make sub-24 without him, but I’m not sure; in any case it would have been a lot closer.

4 weeks later, I’m still basking in the glow of my finish. I still can’t quite believe I did it. I feel like I’ve been outed as an ultrarunner, though. Most people can’t really comprehend ultrarunning, so I don’t talk about it much. But thanks to friends and an article in the Pittsburgh paper, people I barely know are congratulating me and asking me all sorts of questions. My 15 minutes of fame I guess.

My legs are still healing but I’m doing some good runs. I’m trying to take it easy and heal it up and just enjoy my accomplishment. With some perspective, I realize the silver buckle and sub-24 aren’t really of much importance. But to pick a goal like this and work my butt off to achieve it; to come back from injury, those are things to be proud of. After the race, I told Tom I wouldn’t try WS again for at least 10 years, but now I’m not sure. It is a spectacular race with incredible support. I’m already asking my wife if I can apply next year….

Stop Smoking!

If this doesn't curb your cigarette habit, nothing will.

all those bumps are individual metastases of this long-time smokers lung cancer.

Lovely

physicians and unions

Why I'll never join a doctor's union:

The death of a patient in Goettingen, central Germany, is being blamed on weeks of strikes by doctors demanding better pay and conditions. The physicians involved assert that the patient's care was not compromised but a manslaughter inquiry is underway....

Doctors at the University Hospital in Goettingen, central Germany, were in their 13th week of strikes when the 57-year-old patient, named only as Elke S for legal reasons, suffered a fatal heart attack. She had been scheduled to have an intracardiac catheter fitted on June 2, but the operation was put back a week because of the protests, even though poor results were recorded when an electrocardiogram was carried out. The patient died 2 days later on June 4 after her condition worsened at home.

From the latest Lancet, probably no free text. I think by choosing to be a physician you have to put care of patients above your personal interests.

Intelligent design

A good commentary by law professor/medical ethicist George Annas in this week's NEJM about the various guises in which creationists try to "sneak" their views into the classroom. I hadn't realized that "intelligent design" is just creationism repackaged:

By comparing the pre and post Edwards drafts of Pandas, three astonishing points emerge: (1) the definition for creation science in the early drafts is identical to the definition of ID [intelligent design]; (2) cognates of the word creation (creationism and creationist) which appeared approximately 150 times were deliberately and systematically replaced with the phrase ID; and (3) the changes occurred shortly after the Supreme Court held that creation science is religious and cannot be taught in public school science classes in Edwards.

Quote if from Judge John Jones opinion in the recent Dover, PA case adn Edwards refers to a US Supreme Court decision overturinng a previous law requiring teaching of creationism.

Unfortunately, the creationists are gearing up for a new assault, this one predicated on the idea that students deserve to be exposed to both sides of the "controversy" between ID and evolution:It looks as if this next wave will jettison the creationist and intelligent-design baggage and concentrate exclusively on a "teach the controversy" strategy. That this controversy is one largely manufactured by the proponents of creationism and intelligent design may not matter, and as long as the controversy is taught in classes on current affairs, politics, or religion, and not in science classes, neither scientists nor citizens should be concerned.

I don't see why everyone can't just accept that it was the flying spaghetti monster who created everything.

Human to human avian flu transmission?

Health officials have confirmed that bird flu has killed six members of a single family in rural Indonesia, and doctors have tried to determine whether the virus was passed from person to person

While not great news, I wouldn't be too worried yet, either. There has been apparent human-to-human spread before. From the WHO

Though rare, instances of limited human-to-human transmission of H5N1 and other avian influenza viruses have occurred in association with outbreaks in poultry and should not be a cause for alarm. In no instance has the virus spread beyond a first generation of close contacts or caused illness in the general community. Data from these incidents suggest that transmission requires very close contact with an ill person.

As long as this strain of influenza stops in this family I don't think it is any big news. Note also that all the family members were in close proximity to poultry, so they may have all gotten it directly from the birds.

Bronchial thermoplasty

Which articles do and don't get extensive media coverage has always been a bit of a mystery to me, but never more so than this one. Everyone from my sister to my secretary have e-mailed me about this.

I think it is mostly hype. So far, the results of 16 patients treated with bronchial thermoplasty (BT) have been published. That trail had no control group and showed modest improvements in their asthma: days without symptoms increased from about 1/2 to 3/4 of days. The peak flow (how fast patients could blog air out) also improved somewhat. But without a control group we can't know how untreated patients would have done. In addition, the patients in this study had relatively mild asthma.

I might considering this at least a promising avenue of investigation if the intervention was innocuous, but it isn't. The procedure involves putting a flexible tube down into the airway and burning the tissue to reduce the amount of muscle. And once isn't enough; patients get multiple bronchs so that enough muscle can be burned.
Most patients had side effects such as cough or wheeze. In addition follow up was only 2 years, so long term negative effects of the procedure may not yet be evident.

I don't know about you but I'd rather just take my Flovent or Advair twice a day.

In fairness, the article also mentions data from a larger controlled study was presented at the ATS (American Thoracic Society) meeting this week in San Diego, and they are recruiting for an even bigger study.

I'm very skeptical this will be useful. I suspect side effects will be intolerable in the really severe asthmatics who need the treatment most. For milder asthmatics, we already have safe, effective therapies available

The psychological toll of food allergies

Allergists and pediatricians are aware that food allergies lead to a lot of worry for parents. The psychological burden can be overwhelming, for reasons that aren't entirely clear. Unlike asthma, where many families can't be bothered to stick to a medication regimen, some paretns, especially mothers, seem overwhelmed by anxiety with food allergies. I'd guess the difference is that food allergies seem entirely controllable: if you (or your child) avoid the food entirely there will be no symptoms. Asthma on the other hand comes and goes; even patients who faithfully take their medicine will have symtpoms sometimes.

Just how burdensome food allergies are is made clear by this study

more than 60% of caregivers reported that food allergy significantly affected meal preparation and 49% or more indicated that food allergy affected family social activities. Forty-one percent of parents reported a significant impact on their stress levels and 34% reported that food allergy had an impact on school attendance, with 10% choosing to home school their children because of food allergy.

It is a small study (87 families) and there may be some selection bias (the more worried the parent the more likely they are to fill out a tedious questionnaire), but still, 10% homeschooled because of food allergies is an enormous number. I know many families who won't eat out because of concerns of inadvertant exposure. I usually try to get this type of parent to relax a bit, at least to the point of eating out, always checking with the kitchen to make sure the food is safe.

It's not that we have too many doctors

In 2003, the United States had fewer practicing physicians, practicing nurses, and acute care bed days per capita than the median country in the Organization for Economic Cooperation and Development (OECD). Nevertheless, U.S. health spending per capita was almost two and a half times the per capita health spending of the median OECD country

My impression, which could be wrong, is that it isn't that doctors make that much more here, either. From an article suggesting that we'd spend less and more efficiently if we utilized information technology in healthcare more efficiently. I agree, although I don't think there are any easy answers.

Weight loss update

Weight this week: 205

Weight last week: 205

Change this week: 0

Starting weight: 206

Change from start: -3

No change in weight this week, but I am definitely getting thinner. I am reporting my Saturday am weight, which was my lowest in a week last week and the highest in a few days this week, so I definitely think things are going in the right direction.
For more on my diet see here

Calculate your cardiovascular risk

using this calculator. You just need to know your total and HDL cholesterol and your systolic blood pressure.

I come up with a 1% risk of heart attack in the next 10 years, which seems pretty low.

Why we scratch

Why do we scratch?

A simple answer would be because we itch, but how does scratching make itching (or pruritis in doctor lingo) better. But the real answer is

the most characteristic response to itching is the scratch reflex: a more or less voluntary, often subconscious motoric activity to counteract the itch by slightly painful stimuli. This itch reduction is based on a spinal antagonism between pain- and itch-processing neurons

In other words scratching causes a mild, painful sensation that inhibits transmission of the "itch" signal:

I never knew that!

Evolutionarily this makes sense: noxious (e.g. painful stimuli) cause withdrawl, but itching usually signifies something on or under the skin. The pain from scratching prompts closer inspection.

The linked article has everything you'd ever want to know about itching and more.

Shangri-la update

Well I promised to follow the Shangri-la diet and update readers on my progress. I had some issues with illness and injury and didn't really follow the diet for a while. I finally got healthy and over a nasty cold last weekend and started both exercising and following the diet regularly. I'm trying to take 1 tablespoon of extra light olive oil (ELOO in Sharngri-la terminology) 2x a day.

To control for exercise and trying to lose weight, I'm going to compare my progress losing weight to the same time last year when I was also exercising regularly, hopefully at similar volume. Not exactly a placebo control, but at least I'm comparing apples to apples.

The line part graph shows weight at the end of the week in both years and the columns my weekly mileage (which is a combination of running, ergometer running with a few miles added for each strength session). I'll try to update weekly

IQ and health

I've blogger previously about the paradox that class seems to matter more than absolute income in determining health. For example

blacks in the United States have about 4 times the income of men in Costa Rica or Cuba, but about 9 years’ shorter life expectancy.

Part of the answer may be that IQ, not income is a key predictor of health.

A recent study in the BMJ showed that correction for IQ attenuated but didn't eliminate much of the trend toward better health in higher socioeconomic classes (also see commentary here). Of course the two aren't independent as income and IQ are strongly and positively correlated.

This makes intuitive sense as two people with similar IQs but vastly different incomes (say a professor at a small liberal arts school and a manangement consultant) should both be able to follow similar lifestyles from a health perspective. While one makes more than the other, both should recieve good health care and be able to afford things like quality food and gym membership. As we move down the socioeconomic ladder, however, effects of deprivation might become more pronounced even with similar IQs, although in Scotland, access to health care should not differ.

Doctors communicating

Flea has a great post about specialists not giving credit to primary care docs for staring the work-up and, often, making the diagnosis before the specialist even sees the patient:

In his letter, however, the gastroenterologist failed to mention any of the work-up that I had performed, and stated matter-of-factly that he had made the diagnosis.

In a collegial manner, I offered that at best the diagnosis was a joint effort.

My colleague's reply was "My goodness, I didn't think you guys (i.e., you fleas) actually read these letters!"

I respond in his comments, but I'd like to lodge a complaint from the other side of this interaction. Specifically, any workup you do is of no use to me if I can't get hold of it.

Again and again I see a patient referred for "immunodeficiency." Like many kids, the patient has been on antibiotics a lot. The primary (PMD) has sent some lab tests and apparently they were abnormal. I say "apparently" because I don't have them. The parents assumed the PMD's office would send or fax them but they didn't. Our nurses are happy to call, but don't appreciate being on hold for 15 minutes, then being told the office is too busy to fax it over right away. At times I have to personally call the doctor to plead with him to have someone fax them right away. Meanwhile, the family sits for an hour while we wait for the results of these tests. Usually, the tests are fine (one lab locally doesn't correct the "normal" immunoglobulin range for age, so all kids come back artefactually low), and I can reassure the patients, but it would sure be helpful if I had those tests right away.

So, primaries, think about using your consultants wisely. Everyone benefits when the workup you've done is available to the consultant: it makes my life easier, I can communicate what I think to the patient and parents in person not in a phone call later, and unnecesary and duplicate testing is avoided.

UPDATE: added link to Fleas and his original post which I swore I'd already put in.

Free Advice

As medicine increasingly becomes a business, will it's characteristic collegiality be eroded?

As a specialist, I am often asked for "curbsides" about patient I don't see and for which I don't get reimbursed. As one of my life's overall goals is helping sick kids (or keeping them well in the first place) and as a faculty memeber at an institution that promotes learing, I don't particularly mind this. Plus, there may be some indirect benefit in that docs who I give advise to are more likely to send me patients in the future. In fact, many who call for advice already refer a lot of patients my way. Plus, I see most pediatricians as overworked, (relatively) underpaid, and struggling to keep up with the constant flow of new information about how to treat every disease of childhood as well as what is and isn't recommended for well-child care. To the extent I can help, I'm happy to. Heck, I answer all the crazy and not-so-crazy emails I get from people who read this blog and want free medical advice

But a recent experience has me wondering if this kind of attitude won't change. A few months ago I got a call from a physician I didn't know and spoke with him for 10 minutes or so about chronic urticaria (hives). I even sent him a review article on the subject. Later I found out he operates a "concierge" practice in which he charges patients just to be in his practice. The fees are steep (>$1000 a year for younger kids, less for older) and I presume he makes a lot more than the average pediatrician. I found myself a bit mad that he'd felt free to take up my (uncompensated) time so he could pass the information on to parents (probably crediting it as coming from a specialist at my locally prestigious hospital) and justify his fees, which effectively exclude most children.

I'm still not sure exactly how I feel about this issue, and I still talk to whoever calls me, but if calls from concierge docs became more frequent, I'd consider tryng to charge them for advice. My rationale would be they've made their practice into businesses first and foremost, why shouldn't that same principle apply to them?

More CPOE

In December, I discussed a concerning publication from my own institution showing increased mortality in the ICU after implmentation of a computerized physician order entry system.

Well, the establishment has now had it's chance to respond, in a series of letters either critiqueing the study or arguing that the hospital didn't implement the CPOE properly (not that anyone could dispute that). I don't find them entirely convincing, but you can judge for yourself if your institution has free access.

And yes I took and extended break for no real reason. I've had a fair amount going on, got a bad cold, felt like I didn't have much to say, etc. I should be posting more regularly for the next while at least

That's a lot of ecstacy!

From the February issue of the journal Psychosomatics

Mr. A, 37 years old, used ecstasy between the ages of 21 and 30. . . . An estimate of lifetime consumption yielded a total intake of more than 40,000 tablets. At the time of his presentation, Mr. A reported current cannabis consumption, together with a previous history of polydrug misuse (i.e., solvents, benzodiazepines, amphetamines, LSD, cocaine, heroin). After three episodes of "collapsing" at parties, Mr. A finally stopped his ecstasy use. . . . He eventually developed severe panic attacks, recurrent anxiety, depression, muscle rigidity (particularly at the neck and jaw levels), functional hallucinations, and paranoid ideation. The Mini-Mental State Exam revealed disorientation to time, poor concentration, and short-term memory difficulties. Decrease in level of cannabis intake led both to disappearance of his paranoid ideas and hallucinations and reduction of his panic attacks, but remaining symptomatology persisted. Administration of the Wechsler Memory Scale (3rd Edition)3 suggested the existence of global memory-function impairment, with no subtest score being above the 10th percentile. Assessment of daily functioning skills identified major behavioral consequences of his memory loss (i.e., repeating activities several times). Although Mr. A was able to fully understand the instructions given, his concentration and attention were so impaired that he was unable to follow the sequence of the tasks required. A structural MRI brain scan revealed no focal cerebral lesions;

Curiously, a recent commentary in the Lancet (which is where I heard about this individual) suggests that this case demonstrates the adverse effects of ecstacy may be LESS than previously thought:

But the case of a man who emerged from a decade-long period of intensive MDMA use—during which he is estimated to have taken 40 000 pills—with no signs of the profound neurotoxicity that has long been feared to result from even limited consumption of ecstasy, has re-energised calls for more research into the real side-effects, and therapeutic potential, of psychedelic drugs.

One shudders at the thought of the shape this guy would be in if he'd had more bad sequalae.

But there are apparently people who've developed persistent psychosis after a single use of ecstacy. From that case report, here is a description of the various bad things that can happen after using ecstacy:

There is a widely held belief that MDMA is a "safe" drug, but a growing body of literature has documented both medical and psychiatric adverse reactions to MDMA. Medical consequences include renal failure, rhabdomyolysis, disseminated intravascular coagulation, hepatitis, cerebral infarction, seizures, delirium, and coma. In terms of psychiatric sequelae, MDMA use has been associated with depression, anxiety, panic attacks, flashbacks, perceptual changes, depersonalization, and derealization

Other than that it sounds perfectly safe (more here)

TGN1412

It was apparently the medicine itself, not a contaminant that caused the horrific reactions to TGN1412:

A preliminary investigation of a UK trial in which six healthy volunteers became critically ill said this was probably due to effects of the drug in humans not predicted by animal studies. But the report stopped short of questioning how the study was carried out.

The investigation into the phase I trial of the monoclonal antibody TGN1412, carried out by the Medicines and Healthcare Products Regulatory Agency (MHRA), the body that approves clinical trials in England, said the trial was run according to the agreed protocol, using the correct dose. It also found no evidence of a manufacturing problem or contamination of the product given to the trial volunteers.

One problem with animal testing for monoclonal antibodies against human proteins is that they are likely to be much more potent in humans than animals since they are specifically engineered for high affinity for a human protein and may have little or no binding to the homologous animal protein. This is unlike more classic small molecules which are likely to have similar potencies in animals and humans.

Living longer

Death rates in the United Stares are plummeting, according to the National Center for Health Statistics; and the discrepancy between the races is closing. Looking at the figure, I'd estimate an 8-10% reduction in age-adjusted death rates since 2000. I blame George Bush.

Seriously, I'm glad I didn't write an article like this one, suggesting that mortality rates were likely to increase due to the increase in obesity.

UPDATE: missed link fixed, thanks to Flea