Volume , Issue

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In August 2016, we were lucky enough to be invited to provide medical coverage for arguably the most medically complex single sport wilderness race in world:  the La Ultra the High Race. The La Ultra is a race delivered concurrently in 111, 222, and 333 kilometer formats. It takes place in the spectacular former Himalayan desert Kingdom of Ladakh, which is now the Leh district in the Jamu and Kashmir regions of northern India. It is the unique geography of this region that delivers both the spectacular back drop of the high Himalayan vista to the event and also creates such a diverse challenge medically. The 333 kilometer course, which touches altitudes over 5,000 meters three times during its meandering path towards the Changthang Plateau, is truly a unique experience in a sport that is overflowing with outstanding races. There is no entry level option however, as even those competing in the “shorter” 111 kilometer iteration are still required to summit the 5,359 meter pass at Kardung La, infamous for being both the highest motorable pass in the world along with one of the most dangerous.

Kardungla Pass

The course itself has been previously described as at worst impossible and at best situated on the furthest tip of human physiological capacity.  Nonetheless, the 29 men and women who have completed the 333 kilometer path over the previous six years stand as a testament to our bodies’ seeming never-ending ability to surpass and overcome the most extreme of tests.  The collection of 17 competitors who had gathered for this, the 7th edition, were as diverse and unique as the region itself, with a mix of elite international world class runners and less experienced home grown athletes.

Medically, when we started the planning phase, the race offered multiple challenges – with altitude illnesses amongst competitors almost a rite of passage – including exposure, exhaustion, and the expected muscular skeletal issues associated with such extreme distances.  Regional politics also has a role to play with satellite communications banned and helicopter evacuations tightly restricted by the armed forces.  The Region itself is remote with no advanced medical facilities available outside of the provincial capital of Leh and no reliable prehospital system in place.  The sheer course length also creates a medical management nightmare due to extended lines of logistics and communication. 

Medical Briefing

In this case, not only were the 17 actual competitors considered at risk but also the large footprint of vehicle based personal and organiser support crews also required to summit peaks and self maintain for several days fell into our responsibilities. Indeed, whereas the competitors were all relatively experienced athletes and had undergone deliberate acclimatization, many of the support teams arrived in the region mere days prior to the race, and were comparatively ill prepared and ill informed.

The two person medical team arrived in the town of Leh – at an altitude of 3,480 meters – 10 days prior to the start of the race and was made up of a critical care paramedic and an Operating Department Practitioner, both with many years of remote health care experience. The team followed a deliberate acclimatization program of hikes and treks in preparation for the requirement to operate at over 5,000mts throughout the event, and also offered medical cover for media teams pre-race. As always, the number one rule of working in challenging environments is: don’t become a casualty yourself. So, a prophylactic dose of Diamox 125 milligram bid was started and continued throughout the pre-race phase. With the exception of a periodic breathing episode in a team member recorded on night one, no other altitude related issues were reported by the medical team during the trip.

Nick and Tim, the Medical Team

After identifying the issues with communications and distances, it was decided that a proactive non-centralised flexible approach was needed regarding medical support. This would focus on developing a level of self-sufficiency within support teams focussed on early identification and basic management of issues without the requirement for direct medical team intervention.  Therefore, during the pre-race period, several medical training meetings and briefings were held with both the competitors and support crew covering early recognition of altitude and environmental related problems with scenarios including basic first aid and BLS stances. Basic pharmacology such as Diamox was also issued to each support crew with associated training on its use.

It is also worth noting that much emphasis was placed on reassuring the competitors that the medics’ main effort was enabling them to complete the race as opposed to looking for reasons to pull them off the course.  This was done to ensure the athletes did not feel the need to hide early symptoms of illness from the team in fear of being dropped and was generally met with a good attitude. 

Prior to the race starting, two competitors required medical treatment, one for Diarrhea and Vomiting (D&V) and one with large finger abscess that came on during an acclimatisation climb.  The D&V was treated successfully with a single dose of ciprofloxacin in association with IM and PO ondansetron, but the individual chose to move from the 222 kilometer to the 111 kilometer class due to hampered preparation. The second required a partial ring block with lancing and went on with no further issues.  

The start gun fired at 20:00 on the 11th of August. The first 24 hours of the race is always going to be the most challenging as it has all 17 competitors on the ground at the same time. It also has the largest support footprint and also the summiting of the highest point of the race.  This period was initially managed for the first 48 kilometers by leapfrogging the two medic vehicles between the front and rear of the pack.  This allowed for regular assessment not only at check points but also on the drive past the runners, which enabled us to pick up changes in pace and wellbeing early in onset, plus sweep for any collapsed or severely compromised participants. 

 

The going was tough, even for our truck

The initial hours were medically uneventful with two competitors being withdrawn solely due to missed timings which are designed to be deliberately tight.  Temperatures dropped rapidly as the night deepened and altitude increased, leading to enhanced concern regarding exposure.  The 48 kilometer checkpoint (North Pulu) was at a height of 4,736 meters and stationed in a remote chai house with electric lighting, and access to basic food and hot water for teas and coffee. It also was in close proximity to a military controlled helipad which we were told could be used in extreme circumstances.  Due to its bridging altitude, facilities, and worsening external conditions, the team decided to set up an improvised clinic within the chai house itself.  The aim of this clinic was to primarily act as an area of holding and assessment for competitors prior to continuation and increasing altitude. Its second role, however, was to act as an emergency forward aid post to which serious casualties could be evacuated if anything happened on the ascent.  A focus was placed on both the ability to rewarm and reoxygenate patients as exposure and altitude seemed the most likely risk.  However, consideration was also made toward stabilizing trauma patients as best we could prior to definitive evacuation.

Managing a runner at North Pulu aid station 4736 meters

On assessment, all athletes at this point had clear lung fields and showed no altitude related symptoms outside of the expected low saturations, which varied from the higher 70’s to mid 80’s. However, most runners were showing early signs of exposure, with three requiring deliberate external rewarming using sleeping bags along with several hot sweet drinks prior being able to continue. The medical team was limited in interventions by race regulations which stated that anything other than over the counter medications and basic first aid was cause for withdrawal, which included the use of oxygen and IV fluids. This meant a robust approach to assessment was implemented focusing on neurological indicators, such as coordination and mental status, combined with perceived exercise tolerance and respiratory effort. If deficit was found, early blood glucose was taken to rule out hypoglycemia, patients were rested and rewarmed prior to reassessment, and making the decision to escalate treatment and withdrawal. Several athletes were identified as at risk and, although released to continue, were watched using targeted rolling medical checkpoints every two kilometers, implementing a 30 second coordination and respiratory assessment. During this phase one athlete was withdrawn on medical grounds due to signs of ataxia, and a decline in pace and exercise tolerance combined with saturations that were markedly lower than the rest of the field. Transport necessitated transiting over the peak of Kardung Lah prior to descent. However, oxygen was administered and the athlete was taken down to the next check point without further incident.

Whilst the rear of the pack was being managed from North Pulu, the elite runners at the front had increased the gap between lead and last by several hours. This spread required that one medic continue with the leading runners and manage them for all intents and purposes as a separate entity.

With temperatures dropping to -10 degrees C during the leading runners early morning ascent of the Khardung La pass 5,395 meters, concerns were raised over both the record breaking ascent times and the environmental conditions. Therefore, the second medical response vehicle was parked at a strategic point near the summit in order to assess the front runners for both exposure and altitude illness. 

Always time for tea at the 5100 meter aid stations

Sometime after the first runner had summited without incident, the next group of runners were approaching the medical check point. At about 30 meters distance, obvious breathing difficulties could already be heard from one runner with audible inspiratory stridor and a deep bellowing sound noted on expiration. 

The runner was immediately stopped and a focused physical examination of respiratory, cardiovascular, and neurological systems examination was completed revealing the following; 

  • Anxiety
  • Respiration rate: 34 
  • Inspiratory stridor
  • Expiratory crackles, bellowing noise with pursed lips
  • Both lung bases crackles ++
  • Sp02 60 percent
  • Radial pulse 140 bpm, regular, strong
  • Alert and orientated to surroundings
  • Negative ataxia
  • No other signs of neurological deficit

On completion of the medical assessment, a diagnosis of high altitude pulmonary edema (HAPE) was made and the runner was given three options: accept high flow oxygen via non-rebreather mask, rapid descent via rescue vehicle to a height below the first onset of symptoms, or continue the race on foot aiming for a rapid descent the other side of the mountain under close observations. If the runner was deemed to deteriorate in any way during this initial 600 meter descent they would be immediately placed in to the vehicle and given oxygen.

The runner chose to continue under direct supervision and fortunately made significant improvements. On re-assessment at 4,800 meters, inspiratory stridor was still present but lung fields were now much clearer, pursed lips no longer used, anxiety levels had dropped, and oxygen saturations now read 76 percent, which was only 2 percent less than the medics. The runner was deemed fit to continue to the next check point roughly 15 kilometers away where another medical assessment would be performed. This check point was made without incident and on exam further improvements had been made with mild inspiratory stridor present, oxygen saturations 79 percent, but exercise tolerance normal.

On descent from the pass, both the leading and trailing athletes, along with support teams, were met by the inverse of the environmental problems they had recently experienced. The quick loss of altitude and rising sun bolstered temperatures in to the high 30’s, which lead the medical team to find themselves actively cooling individuals they had been trying hard to rewarm a mere eight hours previous. Methods used were drenching of clothes, fanning, basic hydration monitoring, and enforced rest periods in shade, along with continual assessment of the athletes. Despite this environmental inversion, all runners who made it over Kardung La finished the 111 kilometer section of the course.

The highest pass in the world

On completion of the 111 kilometer section, only four competitors remained to continue in the 333 kilometer category, which enabled the medical team to combine into one vehicle. The following 24 hours focussed on supporting the remaining runners up the second 5000 meter plus peak at Wari La which, despite concerns of a repeat episode of HAPE, they accomplished without incident. At the 222 kilometer junction, the competitors all reported only two hours of sleep in 48 hours, but other than the expected tiredness were in good condition. The same was true of the medical team who were, at this point, looking on with an increasing mix of both jealousy and admiration at the local driver’s ability to fall asleep in seconds regardless of comfort level, whilst passing the time increasing their repertoire of yak-based humour.

The next challenge, other than sleep deprivation, was the final summit of Tanglang La (5,334 meters), which holds the title the second highest motorable pass in the world. This final section had historically proved responsible for several drop outs due to the geography providing little protection from the elements and some of the worst conditions on the course. After grabbing our first full hours sleep at a tented check point and a questionable hot meal, the night set in. The athletes pushed onto the mountains and the temperatures dropped to the coldest yet felt, increasing our concerns regarding exposure. 

Again rolling checks were implemented during the ascent in order to check mental status, coordination, and lung fields. Concerns were raised near the summit when two competitors who were running together seemed to be delayed coming through a check point. The medical team descended and found the two athletes stationary and confused on the single trail, seemingly lost. The team guided them to the check point using the vehicle and immediately placed each on a 10 minute stand down for assessment. One competitor was displaying a reduced level of consciousness with associated UMBLES and was immediately placed in a warmed vehicle, with a sleeping bag draped over the patient and air heater in order to improvise a bearhugger. Assessment of saturations indicated a low reading compared to others in the vehicle whilst glucose was within bounds and lungs clear. The patient was told to eat high calorie nutrition and hot drinks were provided prior to reassessment after 10 minutes. On reassessment saturations had improved dramatically and the level of consciousness had greatly increased, with the patient talking normally and feeling good to continue. A neurological assessment showed no abnormalities and the patient had no ataxia. Given that the rest of the route was a descent to the finish, the pair was allowed to continue with the medical team in close proximity. The two went on to finish the course in a record time. The remaining two competitors were more spread out; however, their ascent took place in the day and was uneventful medically. All 333 kilometer competitors continued to complete the course in good time.

Overall the medical team was required on eight occasions during the race itself, with three being altitude related, two environmental, and the rest split between muscular skeletal and soft tissue complaints. Five of these interventions were basic in nature with two being intermediate (Invasive or oxygen) and one being classed as advanced due to non OTC pharmacology being used. 

Asked by local nomads to take blood pressure

CONCLUSION

Overall the race was a challenging but enjoyable experience drawing on all of the teams nearly 20 years’ experience in both remote medical planning and execution. We had some level of luck in avoiding serious traumatic casualties on the roads and conservatively managed the competitors within our comfort levels in order to enable almost all to complete their dreams of finishing. The team is already looking forward to developing their yak-based comedic skills on the 8th edition with much anticipation.

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