Hyponatremia is defined by the Mayo Clinic as a condition that occurs when the level of sodium in your blood is abnormally low. Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells.
In hyponatremia, one or more factors — ranging from an underlying medical condition to drinking too much water during endurance sports — causes the sodium in your body to become diluted. When this happens, your body's water levels rise and your cells begin to swell. This swelling can cause many health problems, from mild to life-threatening. (Www.mayoclinic.org)
Tim Noakes created a stir with his book Waterlogged, discussing the Problem of Overhydration in Endurance Sports. I am currently reading the book, and it does raise many questions about the philosophies of water and fluid intake during training and competition.
Recently, I had the privilege of chatting with Tania Haas, a freelance writer for Canadian Running and Triathlon Magazine Canada. She recently competed in Lake Wanaka 70.3 in New Zealand, and was treated for hyponatremia. Here is her story of Swim, 80K of Bike, Hospital Stay and Recovery- Lake Wanaka:
I'm a full time health writer at www.medcan.com and a freelance writer for Canadian Running and Triathlon Magazine Canada Magazines. I live in Toronto and have travelled around the world writing. I'm also a part-time yoga teacher. My professional website is www.taniahaas.com with more details!
–How long have you been competing in triathlon? What distances?
My first triathlon was in 2008 after I suffered ITB issues during training for a marathon. I did a try-a-tri that summer, then progressed to sprints every other summer after that. In February 2016 I participated in my first 70.3.
–what was the distance for the race you suffered hyponatremia? 70.3–had you competed in this distance before?
– what was your nutrition plan for this distance? (Was it expected to be the same as previous races at this distance)
I didn't hire a coach and I only had a very short conversation with some coaches re: the fourth sport (nutrition) ahead of my race. Since I write for triathlon magazines and work with nutritionists and registered dietitians, I figured (wrongly) that I didn't need customized guidance. My plan was to drink electrolyte water, have bars; and gels throughout and eat when hungry and drink when thirsty. Basically, to eat what was on the course (one of my plans was the following: Clif gel 30 minutes prior to the swim. Once on the bike, give yourself about 15-20 minutes for your HR to settle in, then start taking gels in 1-2 per hour, along with about 650ml of water. You could add some clif bar, maybe a 1/2, but not more, and try to get it early one so you have time to digest it a bit.)
—what were the major differences in your pre-race plan for this race compared to other races?
A much more strict training regime; much more dedicated training.
— did you travel?
Yes, a lot of travel. I travelled from Toronto, Canada to Wanaka, New Zealand. Around 20 hours in the air, 3 days before the race.
— were you healthy going into the race?
I would say I was healthy physically (no blatant injuries) but I could have used much more sleep about a month going into the race. I was working extra hours at my job; and not sleeping enough.
— you mentioned you took a pharmaceutical, prior to race day. Was it an over the counter or a script?
I was stung by a bee/wasp at lunch the day before the race. I immediately went to the local pharmacy to ask for their strongest antihistamine as I swell from bites though I'm not seriously (epi-pen) allergic. So they provided me with the strongest antihistamine available over the counter. I then iced the wound. It was on my upper right neck area, so I was a little concerned about my swim and also my airway.
— had you ever used this med before? No.
— what was you ur body's reaction to the drug?
the bee sting didn't hurt but it was still quote swollen and very hot the morning of the race. So this is where I made a mistake: I took another antihistamine, recklessly, before I left the hotel room on the way to the race. I was paranoid (probably unreasonably so) that the wound would bother me (it didn't). My body's reaction to the drug was not immediate but doctors later told me that the antihistamine combined with the incredible demands on the body perhaps combined with my exhaustion, triggered a condition called SIADH, which may have eventually led to the hyponatremia.
If so, did you have a similar physiological response -during the race what symptoms did you experience?
The race started out incredibly well. My swim was rewarding and wonderful and I shaved off at least 7 mins on my expected time even though it was incredibly choppy. I felt great. After transition and once I was on my bike, however, my mouth was parched. I immediately felt a severe thirst and I drank all my electrolyte filled bottles on my bike and hoped the next drinking station would be visible. On my bike I had three bottles.
1 x 28oz (828ml)
- 2 x 750ml/25oz
I drank them all after every rest stop. Had electrolytes in every bottle.
– at what point did you know you were in trouble?
The dry mouth when I started the bike was odd, but I figured I must have really given'r during the swim and I was dehydrated, so I just drank. I started to experience an odd headache around 40-50K, which I thought was odd, but attributed it to to the humid weather, which was changing from windy to rainy… however, I don't usually get headaches, so again, I thought I was dehydrated. So I kept drinking. It was super hot and windy, so I was sweating a lot! But not going to the bathroom. I only urinated once during the bike and it was very little liquid. I also thought that was odd, but I hadn't discussed peeing during the race with anyone, so I didn't recognize this significance. As I approached the final tent on the bike ride around 80K, my head felt like my brain was hitting my skull (my brain was in fact swelling)… and while my ambition urged me to go forward (and many volunteers bless their hearts (“just 10more K to go! You can do it!”) I requested to see a doctor. While waiting for the doctors to arrive, I down a coca cola, and a banana wondering if it was a lack of sugar. I sat down. My head felt like it was going to explode. I decided to make myself throw up the food, that didn't help either.
–what was the end result?
When the doctors arrived, they asked me about my symptoms, and I told them about my dry mouth and my swollen head feeling. They asked me to get up and walk. I was having trouble walking. I was stumbling and having to gain my balance by holding on to chairs and tables, but I did it. Then the asked me to walk toward their vehicle. I told them, I had changed my mind, and that I was fine, and that I just wanted to finish the bike section, and that I would just walk the run. Okay? Nope. Then they asked me to walk around the car. Then they asked me to sit in the passenger seat. Then I said, “Oh, you tricked me!” and then I passed out. I don't remember the next 12-15 hours.
The race alarm went off. I was ambulanced to the nearest hospital around an hour away. The doctors immediately diagnosed a severe case of hyponatremia. At the hospital, which I don't remember, they somehow released the water in my system and walked me back and forth to the bathroom as the water came out of me through induced urination. Once most of the water had been out of my system, they measured and discovered my sodium levels were at 123, when a normal range I've been told is around 135 and above. This was very concerning. I was told I could not distinguish between a clock and a pen when they were held up in front of me. When my mother arrived to the hospital, I said I couldn't recognize her. My brain was shutting down. The hospital made the call to deliver me to the nearest teaching hospital, which was larger and better equipped to manage a case like mine.
I was transported via an air ambulance from Clyde to Dunedin, a 4 hour car drive but a 45 minute helicopter ride. An ICU nurse sat beside me while I lay unconscious in the back of the helicopter. Once in Dunedin, a blessed ER physician made the decision to inject the sodium back into my system at a distinct rate and pace. This was where I believe my life was saved. Not all ER doctors know or understand hyponatremia, and I was lucky to be in the hands of a physician who did. From around 1am to 7am while my system was being pushed toward equilibrium, an ICU nurse spoke to me, reminded me who I was, where I was, what I had been doing, that I had a condition called hyponatremia – so that if/when I woke up I wouldn't be in shock.
I did wake up at 7am and when asked where I was and if I knew what happened, I recounted exactly what the nurse had been telling me.
Then, the night shift doctor who had saved my life left and a team of fresh faced doctors entered my room. They told me that now my system was at equilibrium, I faced another risk. Because my sodium levels were so low, and my brain cells had been so swollen, there was a risk that the sheath of my brain cells may have been permanently damaged. It's called Central pontine myelinolysis (CPM) and it's brain cell dysfunction caused by the destruction of the layer (myelin sheath) covering nerve cells in the middle of the brainstem (pons). The destruction of the myelin sheath that covers nerve cells prevents signals from being properly transmitted from one nerve to another.
The doctors told me that this possible permanent brain damage would reveal itself in 6 to 8 days. The story of how I responded to this diagnosis and what I did will be recorded in a True Stories Told Live event on Tuesday June 28 and I'm happy to share with you that link for your story. I suffered odd nausea and weird sensations in my brain for 3 weeks or so, and then saw a neurologist two months after the incident who assured me I didn't have permanent brain damage. I did suffer a bout of depression though about 3 weeks after the incident when I realized I survived. A near-death experience can be quite an awakening, and hard to relate to others about. I had to focus on a lot of self care and I sought help from psychologists, a neurologist and general health practitioners to help me understand and build resilience after the experience. –how much training time did you lose?
–have you returned to training?
I've run a 10K. I've returned to casual swimming. But I was told by my neurologist to ease into endurance sports gradually.
–what is you next planned race?
I don't yet have one. I am focusing on my swimming only at this point. When I choose my next race, I'll be working a sports nutritionist and a coach and/or team. –what advice do you have for others from your experience?
+ when training for a 70.3 or above, hire a coach and determine a customized nutrition plan, nutrition is the fourth sport in the triathlon!
+ train in groups (not always alone), so you can talk to each other and share tips
+ consider doing a sweat electrolyte test to determine how much water/electrolytes you need
+ recognize that which can help you can also harm you – re: over the counter medication
+ the 2 or 3 weeks before big race, invest in sleeping!
+ listen to your body during the race. yes, mind over matter is very very important… but being stupid could actually kill you. There's no harm in checking with a doctor and if they give you the a-okay, you are fine to continue the race, go for it! Arrive alive ladies, arrive alive.
I would like to thank Tania, for her willingness to share her story. She did ask me for insights for nutrition strategies in future races.
As a coach, I can provide strategies for this, and refer you to a sports nutritionist who can further help in overall nutrition strategies for your athletic lifestyle. Please do not hesitate to ask.
*note that the photos used in this post are not mine. They have been shared by Tania Haas.*