“Heat Can Kill” by George Sheehan

The following article was written by George Sheehan in his book, “Running To Win”. I purposely wanted this article to be reposted in this blog in order to remind and emphasize to the runners about the danger of heatstroke in running. Many have died due to heatstroke and it is upon the individual runner to take extra precaution on this. On the other hand, it also encouraged that Race Organizers should employ Medical Teams which are trained to deal with heatstroke and better yet, if they are trained as runners also as this article would show that “immediate response and ON-SITE treatment” of heatstroke will make difference on the survival of a victim.

The following is the article as copied from the book. Enjoy reading it. (Note: BDM 102/151 runners should take note on this article)

Heat Can Kill

Despite all we have learned in recent years about heatstroke, runners continue to die from the destruction it wreaks on the human body. These deaths are due to two factors: first, the failure to take the necessary precautions to avoid heatstroke; and second, incorrect management when it occurs.

Precautions against heatstroke are the responsibility of the runner. The protocol to prepare for heat stress, especially encountered in competition, is well established. It includes training in hot weather, carbo-loading, hydrating with fluids, and running at an appropriate pace. During the race, water should be taken at regular intervals as well as splashed or sprayed over the body.

When I run, I wear a painter’s cap in which I place a bag of ice cubes, and I continually soak the cap with water. I never pass a water station without stopping to drink two full glasses and pour one over my head. Wherever there is a hose, I run through the spray, and I carry a cup in the hope that I can fill it with water. And I purposely run 15 to 30 seconds per mile slower than my usual time.

These practices have become so common among runners that the number of heat injuries sustained in races declines each year. Nevertheless, there are always some runners who push too hard, don’t take time to stop for water, or cut corners in other ways. These are mainly highly motivated recreational runners or newcomers to the sport, not veterans. And they are the ones who collapse with heatstroke. Typical symptoms include dry skin, dizziness, headache, thirst, nausea, muscular cramps, and elevated body temperature.

Heatstroke can be a catastrophe, but it need not be. Despite the seriousness of the situation—it’s potentially fatal—correct medical care can and will save the day. And by correct care, I mean the type provided by disaster teams at two of the biggest races in the world run in high heat stress conditions—the Sydney City-to-Surf Race in Australia and the Atlanta Peachtree Run in Georgia, held in July.

While we continue to see random reports of people succumbing to heatstroke, the Sydney medical team has supervised 200,000 runners without a death from heatstroke. In a nine-year period, only two patients were even hospitalized.

There is good reason for this—immediate treatment. Dr. Rowland Richards thinks his Sydney group has arrived at the correct way to treat heatstroke and the correct place to do it: at the race site. Getting a heatstroke victim to a hospital wastes precious time, risking delay in diagnosis and treatment. John R. Sutton, M.D., professor of medicine at the McMaster University in Hamilton, Ontario, Canada, agrees: “Hospitalization may be the very worst approach, especially with subjects whose vital organs are cooking at 107 to 109 degrees Fahrenheit.

That, in a nutshell, is the problem. Fatal heat injury is the result of prolonged exposure to high temperatures. The Sydney physicians are able to reduce initial core body temperatures, taken rectally, of 107 to 109 degrees Fahrenheit down to 100 degrees Fahrenheit in as little as 50 minutes, on the average. This is achieved by applying instant cold packs over the neck, armpits, and groin, along with rapid intravenous rehydration, in every runner with a core temperature of over 100 degrees Fahrenheit. If low blood sugar is suspected, 50 cc’s of 50% glucose is given intravenously. “Failure to follow this routine,” says Dr. Richards, “could result in serious consequences, including death.”

Fortunately, in the one instance in which a heatstroke victim was not given this therapy (a misdirected ambulance was 40 minutes late, then took him to the hospital), the runner did survive.

The Atlanta medical team works on much the same principle. Again, the emphasis is on cooling. Joe Wilson, M.D., the physician in charge, stresses the urgency of bringing down the temperature as quickly as possible. Often this is all that need to be done. Within 30 minutes, patients are usually alert, no longer nauseated, and able to take fluids. If not, intravenous fluids are started. And as in Sydney, no runner has ever died from heatstroke at the Atlanta race.

After reading Dr. Richards and talking with Dr. Wilson, I realized that preventive measures are important, but nowhere near as important as adhering to a tried-and-true protocol aimed at rapidly reducing core body temperature. A heatstroke is a heatstroke. A runner can do everything right and still push himself or herself into a heatstroke as severe as one incurred by an untrained, unacclimatized beginner. At that point, the runner’s life may depend on on-the-spot treatment by an experienced disaster team.

“What is required,” says Dr. Sutton, “is an immediate diagnosis, followed by rapid cooling at the site of the race. Each moment’s delay may worsen the outcome. It is no longer acceptable to have some amateur “ad hoc” arrangement.”

The facts bear that statement out. When we have amateurs running in hot-weather races, we should not have amateurs treating them.

Even the presence of the best professional  on-site disaster team should not keep you from doing your homework, however.


Weakest Link

My Observations and Insights on Running and Heatstroke:

1. In the summer of 1971, two of my classmates died due to heatstroke after participating in a 10K run in Fort Magsaysay, Palayan City (Nueva Ecija) as a “fun run” with the Special Forces of the Philippine Army where you don’t see any Water Aid Station along the route. The race started late in the morning as most of my classmates finished under the heat of the sun. I saw with my own eyes while two of my classmates convulsed and crawled on the edge of the road, few kilometers from the finish line until they were picked up by the Camp Hospital’s Ambulance. Four of my classmates were evacuated at the Fort Magsaysay Hospital but the two of them were able to recover after a day of rest at the hospital. One of my classmates won the “fun run” as he had been a seasoned runner before he entered the Academy.

2. I saw how my two classmates convulsed and sedated inside the hospital. After a few hours, one of them died. On the following day, the remaining serious patient was transported to V. Luna Medical Center using the Ambulance but after his arrival in Manila, my second classmate died also. The doctors and medical staff at the hospital informed our Tactical Officers that our classmates died due to heatstroke! I don’t have any information if the said incident was fully investigated by the Philippine Military Academy and AFP authorities then. However, my deceased classmates were brought by the PMA authorities in their respective places/towns and they were buried with full military honors and their respective parents received death benefits due to a dead soldier/officer of the AFP. Case closed!

3. Two of my classmates who recovered with the case of heatstroke on that fatal day in the summer of 1971 were very lucky. One of them retired from the PNP two years ago as a two-star General/Police Director while the other one was dismissed when we were on our second year due to failure in Academics but had pursued/finished his College studies, worked in one of the telecommunication firms and now resides in the United States with his family. Both of them had never attempted to train or run in any of the road races since this incident.

4. Fast forward to the last week of January 2009 (last year). Jerry Karundeng, an Indonesian studying in the Philippines, joined the “50K test run” in preparation for the 1st edition of BDM 102. He is a strong runner but he is also a “hard-headed” runner that he did not follow my advise and “tips” while we were running on the course. He was wearing a black shirt, did not drink in every hydration station, was not carrying a hydration belt, and his pace was too fast in relation to the hot condition of the day. His mind was so conditioned to use Pocari Sweat as his sports drinks while my staff was serving Gatorade as I believed, they have the same use for hydration in endurance sports. Jerry finished the “test run” but on his way to Manila while aboard a vehicle, he started to experience “signs & symptoms” of heatstroke. Thus, he was brought immediately to a known Medical Center in Makati. According to my interview with Jerry, the Doctor/Medical Staff who attended to him did not believe that he just finished a 50K run under the heat of the sun! He was given with IV fluids immediately with the thought that he was dehydrated. Jerry was lucky that his body systems stabilized and had undergone some blood test in the said hospital. He was released on the same day that he was brought to the hospital and he was able to commute from Manila to Silang, Cavite. A day later, he consulted their resident doctor in their school and showed him the results of his blood test, the resident doctor explained to him that his blood sodium content was way below the average level. It was a conclusive evidence that Jerry was on the verge of being a victim of heatstroke. (Note: You can read more of the details of Jerry’s experience in his blog at www.highaltitude.wordpress.com)

5. On August 23, 2009 after the CAMSUR 70.3 Ironman’s last athlete reached the Finish Line, the Race Organizer admitted to media reporters that one of the participants, a Senior Executive and Owner of a Corporate entity, died during the triathlon event and he admitted also that a thorough investigation was being conducted. The news was reported on line and in the printed edition of the Philippine Daily Inquirer as soon as possible and it was featured at TV Patrol a day after the event. (Note: This is the exact opposite of Remus case where PDI reported his case on line and its printed edition exactly 14 days after the marathon event!!!). However, up to this time, nothing had been officially published if the casualty was a victim of heatstroke that resulted to a heart attack. 

6. In the 34th MILO Marathon Manila Elimination last July 4th, Remus Fuentes died two days after he was diagnosed as a victim of heatstroke which led him to succumb to a fatal heart and organ failures that resulted to his death. After a few days, Alexander Landera from Cebu City fainted or collapsed in the middle of a road race held in the same City where the race was held in the evening. He was brought immediately to the hospital to be treated. Unfortunately, when he regained consciousness, he started to be incoherent, confused, hallucinating, and thought that he was still in the race. Due to multiple wounds and loss of blood as a result of uncontrollable actions on his part, he died. Both runners were victims on separate road races, belong to different ages and running backgrounds, races held in different locations, different race distances, different weather conditions, and different parts of the day when their respective races were conducted (Remus’ race was in the morning while Alexander’s race was in the evening) and despite such factors, both runners died due to heatstroke! However, in Remus Case, the father was able to document his observations on what the Doctors/Medical Staff had done for his son’s treatment in the Hospitals where his son was admitted.

7.  So, what am I trying to say in this post? With my observations, researches and interviews, I firmly believe that our Doctors/Medical Practitioners could not distinguish if an endurance athlete (runner, ultrarunner, cyclist, triathlete, swimmer or hiker/mountaineer) is a victim of heatstroke or dehydration. Anybody could say that he or she is a “running expert” and say to high heavens and to all the media and Internet outlets/sites all the things and advises as preventive measures from being a victim of heatstroke and dehydration but what should be addressed is on the correct and appropriate treatment of heatstroke. I think, the problem lies on how our Doctors and Medical Practitioners in Hospitals react and treat endurance athletes who are victims of such mentioned heat-related injuries. This is the “weakest link”!!! Correct me if I am wrong, our Doctors (who are not seasoned/competitive runners) do not know how to deal with such cases!

8. In the book “Lore of Running” by Dr Tim Noakes on page 235 states that, “the major factors causing heatstroke during races are: environmental conditions; the speed at which the athlete runs; and individual susceptibility, including whether or not the athlete has preacclimatized to running in the heat. If longer distances races (5K and above) have a prevailing temperature condition of greater than 28 degrees Centigrade, heat injury will occur to a significant number of competitors, regardless how much amount they drink and sponge during the race or how they are dressed. Adequate fluid replacement during racing is only one of the many factors that reduce the risk of heat injury; it is certainly not the only factor and may not even be a very important factor. Aside from “hot and humid” temperature as one of the factors that determine the rate at which an athlete loses heat, clothing is also considered because the more clothing people wear, the less heat they will lose by convection and sweating. The athlete’s state of heat acclimatization (training to heat exposure) and state of hydration (not allowing yourself to be dehydrated) also determine the rate an athlete loses heat from his body.” It could be weird but Dr Noakes believes that only certain people are prone to heatstroke and it could be hereditary, too!

9. In Dr Noakes’ book (which I consider as my “Bible” in Running), a heatstroke victim has a body temperature of more than 40 degrees Centigrade; he/she breathes heavily; and has a rapid pulse rate of 100 or more beats per minute. A heart attack victim has a weak heart beat & pulse rate and the patient does not breath. In a heatstroke patient, a rectal temperature reading should be administered first to find out the exact body temperature of the victim. If the temperature readings indicate a result of 40 degrees and higher, the victim’s torso should be submerged in a tub or container full with ice or ice-water for the duration of 3-6 minutes until the temperature decreases to the normal level of body temperature. After the body temperature has dropped to its normal condition, IV fluids and other blood tests can be administered to check if the victim is dehydrated or if there is kidney damage or organ failure.

10. In simple layman’s term, diagnosing and treating heatstroke is very simple. But according to my favorite author and strategist On War, Carl Von Clausewitz, “The simplest things are the hardest things to do”! And be always safe and careful from the dangers of the sports and way of life that we love and enjoy but always remember that, “Shit Happens” when you least expect it from happening.

R.I.P. Remus Fuentes

The following is the Summary Report on the death of Remus Fuentes written by Rudy Fuentes, father of the victim, as gathered from witnesses, his personal observations, and insights. Obviously, this is just one-side of the story and I am still waiting for the Official Statement from Team MILO/NESTLE, Phils and the Race Organizers. I will reserve a post in my blog for such statement.

However, the fact & reality remain…A runner died due to running/participating in  a road race and the running community should be aware and well-informed on the effects of this sports and we have to learn some lessons from this incident and prevent this from happening in future road races.

REMUS FUENTES died of multiple organ failures as result of heatstroke secondary to severe dehydration two days after he ran the 21K in the recent 34th Milo Marathon last Sunday, July 4, 2010.

His death was the result of fatal mistakes, incompetence and negligence in the event organized by Organizing Team.

Photo Provided by Mr Rudy Fuentes

My son, 37-year-old Remus ran the 21K together with a running buddy when he collapsed at 19.9 kilometer mark. There was none of organizer’s ambulance nor marshals to respond in the incident. Policemen hailed for a taxi and they, together with his buddy, assisted in bringing him to the nearest hospital, Ospital ng Maynila. At the ER, the diagnose was suspected heart attack. My wife and me, upon being informed by his younger brother, Roy Fuentes, who also ran the 21K, rushed to the hospital and saw that Remus in coma, had seizures and struggled breathing in spite of hand-pumped oxygen and dextrose attached. His body temperature was 40 degrees C and when asked, the medical attendant told us he had fever. She introduced paracetamol intravenously twice at interval of about 15 minutes. Remus continued having seizures even until the arrival of Medical City doctor & ambulance attendants that we have arranged for his transfer. The Medical City doctor attending said his status was unstable, contrary to the earlier advice to her by the Ospital ng Maynila ER doctor. They rushed him  with the ambulance to Medical City at about 11:30 AM. There, a  series of tests were done, including blood chemistry, CT scan, etc. Cardiologist told us his heart was strong and no intervening medicine was necessary. Blood Chemistry results showed positive findings on creatinin level, an indication of  kidney failure. They suspected liver failure too. To stop his seizures, Remus was put on full sedation for 12 hours. Kidney functions further deteriorated after 36 hours. Blood pressure and heart rate went erratic. Doctors attending him in the ICU asked our permission to do dialysis and blood transfusion to stabilize his blood pressure.  Seven hours later, ICU nurse woke us up and asked us to rush to the ICU. We saw 18 medical people around him, several taking turn doing the CPR. Failing to revive him, the doctor asked our consent to stop the CPR after 15 minutes. We begged them to continue hoping for a miracle. 30 minutes further, doctor told us again that all numbers in the monitoring board “were bad” and asked again the consent to stop the CPR. Finally, we relented. Few minutes later, his heart rate monitor went flat. All these happened in front of his mother and me. We lost Remus 48 hours after he collapsed into coma which he has never recovered. His young wife and his eight-year old son took the news very badly.

About Heatstroke:

It usually happen in extreme sports like basketball, football, boxing and marathon.

Heat stroke is a life-threatening medical condition. The person’s cooling system, which is controlled by the brain, stops working and the internal body temperature rises to the point where brain damage or damage to other internal organs may result. The body temperature, usually at normal 37 C, goes up during the exertion of effort as result of the increased heart rate. When it reaches 40 C, the person is in danger of getting heatstroke. Above 40 C and mostly at about 42 C, the person can collapse into unconsciousness.  If nothing is done within few minutes, he can slip into coma and brain damage may occur. The proven first aid response for heatstroke is cooling the body rapidly in whatever means to the level of below 40 C before bringing him to a hospital.  Ice and water is the best way to do this, the same way it is done for a child having high fever who has convulsion.

Another way of understanding heatstroke is comparing it to the performance of car engine. At idling, the engine temp is low and safe. At sustained high speed, engine temperature increases rapidly but because of the cooling system, the heat is continuously dissipated in the radiator and safe temperature level is maintained. But when the water in the radiator is gone, Undissipated heat will rack up the engine temperature and ultimately exceeds the safe limits. At this condition, engine breakdown will occur in minutes starting with broken piston rings, rods, pistons, etc.

With the human body, perspiration cools down the body so hydration by drinking water is essential. Without water, perspiration stops and body temperature goes to critical level and into heatstroke and then organs and brain begin to fail.

Big obvious difference between human body and car engine is that you can always overhaul the engine but you cannot do that on the human body.

Why Heatstroke is More Dangerous in Marathon than in other Extreme Sports?

In basketball, the player exerts extreme effort only in bursts, stopping or slowing down intermittently which slows down heart rate and cools down the body. At timeout, they drink to replenish lost body water hence you always have the waterboy. Heart stroke is rare but ask any PBA player what they do when a player collapse. They don’t move the body but cool them off with water or ice before bringing him to the hospital.

The same is true in football and in many similar sports.

In boxing, in between rounds of three minutes, boxer rests and drinks water. We can only wonder what will happen if the rule of the sport is drastically changed and will only end when one is down and out.

In Marathon, the risk of heatstroke is much higher for the following reasons:

  1. The long distance runner aims for shorter time as a goal and therefore motivated to keep a sustained effort, not unlike cars at high speed in the highway.
  2. Furthermore, the target minimum time set by the organizer adds more to the motivation to run faster. The cut-off time added more pressure to the marginal marathon runner, meaning if you are used to run above the target time, the tendency is to do better time, probably at pace unproven by your body in practice. (Milo Marathon set the target for 21K medal at 2 ½ hours or less. Remus collapsed at near 20th km. with time of 2 hours 10 minutes when his previous record was 2 hours and 27 minutes. ).
  3. The more critical factor is that the hydration management is not in the control of the runner. He has to rely on water availability at the water stations provided and planned by the organizer along the route. ( In this 34th Milo Marathon, several runners including Remus brother, Roy and Remus running buddy asserted that practically there was no water to drink in the last 2~3 kilometers before the finish line, a fatal failure for Remus by the organizer when they changed the route resulting in merging and over-traffic near the finish line. There were record 28,000 runners on that day and the organizers failed to anticipate the complexity of hydration management. Milo’s last year marathon participants were well below 10,000 runners.)
  4. The correct life-saving response for heatstroke depends on few knowledgable people who may happen to be around the person. To mitigate this, the organizer deploys ambulances with water & ice for cooling heatstroke victims and is expected to respond within minutes. In addition, marshalls are provided along the route to assess runner situations continuously. (Obviously, the organizer failed again on this aspect because Remus was helped by policemen and his buddy instead. By this time, Remus is probably already brain damaged as evident by his seizure at the hospital. No Milo people knew of Remus case on that day until Roy, his brother, sent an email informing the organizer of the incident in the next morning)
  5. The Sun Factor adds to the danger in Marathon. Running under the heat of the sun in tropical country like ours cannot be underestimated. To minimize the effect of the sunheat, Marathon run is planned to finish in the early morning avoiding the heat at later time. Organizers usually take this into consideration. (Milo organized the 21K to start at 5:30 AM , a departure of common practice of  other marathons which started at 5:00 AM.  Remus collapsed at about 7:57 AM. Roy, who is a better runner than his brother Remus, complained that it was unusually hot that morning even if he was able to finish it earlier in 1 hours 45 minutes )

Clearly, Marathon is an extreme and dangerous sport even to the young, healthy and trained runners. This is not the “fun run” many people confused of.

The organizer has clear life-and-death responsibility to make sure that the conditions the runners will run under item 3, 4 and 5 above are done properly. Obviously they did not do their job properly in the 34th Milo Marathon. In my opinion, being the father of Remus, Milo Marathon Organizer have failed my son. It is their incompetence and negligence of their duty that results in the death of Remus …an unneccesary death.

About Remus:

At the time of his death, he was an IT project manager of Hewlett-Packard (HP) responsible in computerizing big companies like Unilab, Coke,  etc. including installation of hardwares (servers, etc.) and software system. He used to work for Intel for 10 years before he moved to HP 3 years ago. He graduated in Computer Engineering. He left a housewife, Takako and two children, Raphael, 8 years old and Therese, 4 years old. Raphael is enrolled at La Salle Greenhills. He played basketball with his brothers regularly on weekends. He has been running since his high school days in Lourdes School of Mandaluyong. He has run many 10Ks and two 21Ks before these, the “Freedom Run” in June 13 and “Nature Valley” in May 20 only this year. He has no history nor complaint of illness and he lived clean.

My Questions for the Marathon Organizer:

  1. How many died in the 34th Milo Marathon last July 4? Is it true that there was another runner at 42K who collapsed at 33 km and later died?
  2. How many runners collapsed in that marathon due to heatstroke who later survived but now are no longer the same person as before due to partial brain injury? At Ospital ng Maynila, we saw a 2nd runner brought in unconscious and woke up later but he can no longer recognize his family. Do the Organizers knew this? What happened to him. Are there more?
  3. Is it true that another 36 year-old runner, Fidel Camson, who ran the 42K 31st Milo Marathon in November 2007 collapsed near the finish line, brought to the Ospital ng Maynila and died later of undetermined cause? If true, what did they do to avoid a repeat which apparently did not happen in this 34th Milo Marathon? If true, why do they still keep the same Marathon organizer for 10 years until now?
  4. Do they keep tally of deaths in the 34 years of Milo Marathon? Do they study the statistics and establish how many died of heatstroke, the preventable one?
  5. What is the corporate culture of the Organizers regarding its respect of the value of life? Upon knowing the death of my son Remus, A Senior Vice President of the organizing team, who head its Beverages Business Unit went to see me and among other things, he told me that the Marathon is continuously improved and but sometimes “lapses occur and they will learn from these lapses”. Lapse is defined as  a ‘mistake’. People learn from ‘error’, a deviation from being correct but a ‘mistake’ is caused by a fault: the fault could be misjudgment or carelessness.  We learn from ‘error’ but we take action on ‘mistake’ and more drastic action when people die of this ‘mistake’. So death in my son’s case is a mere  learning process for this person? Is this the culture that pervades in their Organization? or only in him?
  6. Is the measly “humanitarian” offer to help the family shoulder medical & funeral expense to the family had become an SOP too often? Was it their expectation that as appreciation of this help, the family will keep quiet about the whole thing? Do they really think that the waiver signed by the runners protect them from being liable? Do they know that this waiver won’t apply if negligence of their duty as organizer can be established? 
  7. What did the Organizers do, if any, to keep the news of Remus death from appearing in the media even after one week? Not one news item of his death appeared in the newspaper, TV or radio. Could  the news  of “ HP Manager Died of HeatStroke during the Milo Marathon” not interesting to the public? Were they afraid that the bigger news is when the subline “Father charged Milo Marathon Organizer of Incompetence and Negligence” which may damage the public image of the company?

The answers to these questions will help enlighten the public whether Milo Marathon is safe or not for the runners. To the runners, their parents, wives and relatives…they all better ask these questions before the runners decide to run in Milo Marathon.

Last Words from Remus Father:

I am not condemning the sport but the organizer who failed to make sure runners will not die of heatstroke, when the risks can be greatly minimized with proper route planning, hydration management and quick medical response. I am condemning the contribution of the apparent culture of the sponsor of diminished value of human life as indicative of its senior executive’s attitude that my son’s death is a result of lapses. My hope is something good will come out of Remus death and as result of improved organizing of the marathon run,  few lives will be saved from heatstroke. My other hope is to get justice and for the Organizing Team to  answer for his untimely death. I am working on it.

Rudy Fuentes, Father of Remus