Grand to Grand Ultra


Joshua Mularella is the Medical Director for the Grand to Grand Ultra and Mauna to Mauna Ultra. He is a board-certified emergency medicine physician and the Director of EMS and Prehospital Medicine for Cambridge Health Alliance in Massachusetts. Josh was a US Navy medic for 6 years prior to medical school. After his residency training in Philadelphia he completed a year-long fellowship in wilderness and expedition medicine at SUNY Upstate in Syracuse, NY followed by the Diploma of Tropical Medicine & Hygiene in Liverpool, UK. He is also a Fellow of the Academy of Wilderness Medicine (FAWM). He has published in the fields of EMS and wilderness medicine and continues to be involved in resident/fellow education. Josh has worked at various expeditions and ultra-marathons such as the Southwestern US, the Amazon jungle in Brazil, Cambodia, Sri Lanka and Bhutan. He has been involved with G2G since 2013.

As you prepare for the Grand to Grand Ultra and Mauna to Mauna Ultra, we recommend that you give some thought to medical aspects.

Our Medical Director, Josh Mularella, will be giving some helpful tips on this page and will also be in touch with entrants through our Facebook Group.

Hello to all registered athletes! We're looking forward to a great race this year, and I'm excited to be involved.

This first discussion will be centered around things to consider during preparations, and then we'll drill into other topics as we move along. Questions are encouraged on Facebook where I'll try to address anything that comes up.

When I begin race medical preparations there are FOUR distinct considerations that come to mind:

1. Racer medical background

Have you planned an appointment to discuss the race with your physician? Have you reviewed the medical form we require which includes a check of your immunization against tetanus, for example? Do you have a medical condition which will play a role in your race strategy? Have you had a conversation with your physician about management of this? Runners who have a heart condition, seizures, asthma, or diabetes should have already had these discussions, and should have started to make specific plans. Remember, that the Race does not particularly discriminate against runners with medical problems, nor does the medical staff "clear" anyone to run it. This decision is between the athlete and their physician. Believe it or not, I've worked races where athletes skimp on the discussion with their physician because they think they'll be safe on the course as long as there's doctors around. This is dangerous logic.

2. Hydration and Hyponatremia

Staying Hydrated – The Safe Way
by Aaron Reilly, DO

When it comes to endurance events, having a hydration plan is one of the most important strategies to solidify. Most racers are aware that not maintaining adequate fluid intake during the race can lead to dehydration, and dehydration is bad. What a lot of racers aren’t aware of is that there are complications of over consuming fluids as well, which range from uncomfortable to potentially fatal.

Most runners have experienced “slosh stomach” – the feeling of a full stomach, nausea, bloating, and sometimes vomiting that occurs while drinking fluids during a run. A more serious complication of over-hydration is known as “water intoxication”, or exercise associated hyponatremia. This is caused by dilution of the sodium in the blood due to free water retention.

In regards to hydration, maintaining the zone between dehydration and over-hydration can be difficult. Several strategies to prevent dehydration include monitoring frequency of urination, urine color, and drinking on a set schedule. The problem with all of these techniques is that they really aren’t reliable and can lead to over-hydration. This is because prolonged exertion causes changes in the way that the body normally handles fluid management and urine concentration. It does this by increasing a specific hormone, anti-diuretic hormone (ADH), which triggers the kidneys to retain water. This decreases urination, and makes the urine darker and more concentrated. Therefore, it is possible to have highly concentrated urine and decreased urination and actually be over-hydrated.

While it is common to attempt to prevent water intoxication by consuming electrolyte tablets, there is no data to show that this method is effective. In fact, there is some evidence to shows that high doses of sodium supplementation actually increases thirst, which in turn increases the amount of fluid intake. Since prolonged exertion, among other factors, triggers ADH, the kidneys retain more free water, and may actually increase the risk of hyponatremia. Electrolyte tables can also decrease gastric motility, which means that more fluid will remain in the stomach and may lead to slosh stomach.

So what is the best approach? The answer is it depends. There are many factors that affect sodium loss and fluid retention. My advice is to stay consistent. If you choose to use electrolyte supplements, make sure to train with them. Also, make sure to use the same brand and the same amount during the race that you train with, as different brands will vary drastically on the contents of the supplement. Drinking to thirst is the first step – if you are thirsty, drink up. In addition, pay attention to your urine, but not in the traditional sense. If you are drinking to thirst, but have very dark urine or decreased urine, a trial of modestly increasing fluid intake is reasonable. If this does not lead to increased urination, then the issue is probably less related to dehydration and more related to ADH. A good strategy in this case is to take a 10-20 minute rest (or until you are able to urinate). Pausing from exertion will often lead to decreased ADH and increased urination.

In summary, it can be difficult to maintain the balance between dehydration and over-hydration. The keys are training how you plan to race, drinking to thirst with minimal deviations, and taking urination breaks will often let you know how your body is doing. Pay attention to your hydration and try to keep things consistent, and you will be able to maintain a suitable equilibrium.

Final thought: if you've ever been diagnosed with hyponatremia related to a race, please directly email me as soon as possible.

Check out this recent podcast covering these topics:

3. Heat training

Getting your body acclimated to the heat can be your biggest advantage. You can get considerable benefit from exercising in the heat after just 5 days, and those benefits are likely to be retained for a few weeks. General conditioning is the best way to prepare for the heat if you can't exercise in the heat directly. Again, specifics for training can be found in many books on the subject of ultra running.

My favorite author for all things ultra running is TD Noakes.

4. Blisters

Part of your training and preparations should include blister care. The medical staff cannot possibly stock enough supplies for all blisters on all runners. Part of the race culture and ideals of self-sufficiency include ability to care for the EXPECTED injuries such as blisters. You should start considering what supplies you'll need, and start to develop the skills required to care for your feet adequately. The internet has a myriad of resources on foot care. The medical team will be on standby to encourage and teach foot care as needed, but we won't have the resources to perform daily foot maintenance on runners.

Jeremy Joslin covers this topic here:

5. NSAID/Analgesic use

NSAID and other analgesic use by endurance runners during training, competition and recovery

By: J Joslin, MD; J B Lloyd, MD; T Kotlyar, BS; S M Wojcik, PhD

Background. An increasing popularity of ultra-endurance events coupled with excessive or inappropriate non-steroidal anti-inflammatory drug (NSAID) use during such events could pose considerable potential risks to runners’ health.

Objective. To evaluate the incidence of NSAID and other analgesic use in distance runners during training, competition and recovery.

Methods. We performed an observational cross-sectional study at the Desert Race Across the Sand race (Colorado to Utah, USA) in June 2011 and the Empire State Marathon half-marathon, and relay races in Syracuse, NY, October 2011. A total of 27 ultramarathon runners and 46 marathon, half-marathon and marathon relay runners participated in the study. Surveys were distributed to runners during race registration. Self-reported use of common analgesic medications during training, racing and recovery was assessed.

Results. Among all runners at all stages, NSAIDs were the most commonly used analgesic medication. NSAID use by ultramarathon runners compared with all other runners was similar during training (59% and 63%, respectively; χ2=0.008; p=0.93) and recovery (59% and 61%, respectively; χ2=0.007; p=0.93). However, ultra marathon runners were more likely than all other runners to use NSAIDs during the race (70% and 26%, respectively; χ2=11.76; p=0.0006).

Conclusion. Despite undesirable side-effects associated with the use of NSAIDs, there was a high prevalence of use in all runners, particularly during training and recovery. NSAID use during the race was significantly greater in ultra marathon runners. Medical staff at endurance events need to be aware of, and prepared for potential complications related to the high use of NSAIDs in runners. Future efforts should focus on teaching runners about the undesirable effects of medication and emphasising alternatives to pain medication.

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