We regularly hear from athletes who've suffered from a bout of exercise-associated hyponatremia, a condition involving the dilution of your blood sodium levels, usually driven by excessive, low sodium fluid intake during prolonged exercise and potentially exacerbated by high salt losses in sweat.
It's symptoms including nausea, vomiting and - in severe cases - seizures, coma and even death.
It's a topic close to our hearts and one we've even contributed research to, having a paper published in the BMJ last year.
Often the stories we hear 'only' involve race/day-ruining experiences and the athlete is looking to beef up their hydration strategy to ensure it never happens again.
But occasionally we come across case studies that are more extreme and life-threatening, such as the story of the British Army Officer who collapsed twice whilst on deployment in hot climates, or ultrarunner Wookie Kim, who had to be airlifted out of the Rockies and into intensive care with severe hyponatremia and other altitude-related conditions.
Wookie reached out to us with his story and we thought you'd find it interesting...
So, Wookie, a few years ago you had a near death experience triggered by altitude and hydration issues whilst running in the Rocky Mountains, what happened?
That's a long story but the short(ish) version is that I developed high altitude cerebral edema (HACE), high altitude pulmonary edema (HAPE), and severe hyponatremia (low blood sodium levels) while attempting the Four Pass Loop, a 27-mile trail that gains 8,000 feet and hits four 12,500-foot mountain passes in the Maroon Bells Wilderness Area near Aspen, Colorado.
It was a harrowing and humbling experience, and one that has changed the course of my life in several big ways.
Can you talk us through your symptoms and how things unfolded?
The first thing I noticed is that my running pace had slowed down relative to my friend Will. Earlier in the run we'd been running a steady, consistent pace - together. I didn't necessarily feel more tired. I checked my heart rate and it was still safely in the aerobic zone. Yet, something just felt off and I begin dropping behind Will as he cruises ahead.
By mid-morning, Will starts noticing that I'm stumbling over in several places on the trail with unchallenging footing. When he asks how I'm doing, I tell him I have a headache. I tell him I'll monitor the situation. Internally, I begin thinking, "do we turn around?".
As we descend further, my head began hurting more, so we decided to stop, take a water break, take some ibuprofen from the med kit and then decide on a course of action. As we sit on the side of the trail, I feel hazy. This is not normal. I tell Will we have to abort the run.
When we made that decision we were just about as far from the trailhead - or any other exit point - as we could get. I started experiencing problems with my vision and balance and I fell several dozen times. I had a splitting headache, began to vomit and eventually I lost my ability to walk and ultimately experienced seizures and went unconscious.
People tend to wonder how I could have let the situation get so bad. The truth is that, by the time I realized that my condition was far worse than "normal" altitude sickness, it was too late.
Thanks to my friend's heroism, as well as the selflessness of three backpackers who stopped to tend to me while I was convulsing and vomiting while passed out, a dozen members of Mountain Rescue Aspen came out to rescue me.
Because my condition was determined to be dire, MRA ultimately chose to call in a night-time helivac, and that's how I got off the mountain and to the ICU. They rescued me in the nick of time. I was on the verge of dying during my first night in the hospital and I was in a coma for several days after that.
While the recovery process was long, I can thankfully say that, today, two and a half years later, I've made a 100% recovery on all fronts.
Nasty! Did those who treated you offer explanations as to why you'd suffered those conditions?
I have a 3-inch stack of medical records from my time in St. Anthony Hospital that reveal that I was treated by many different doctors and medical professionals!
Although most of the critical treatment occurred while I was in a coma, I did ultimately learn from my primary doctor that there was no definitive reason for why I'd suffered in such a serious way.
The situation had stemmed from a multitude of factors working together. These include that I live at sea level, I was experiencing a lot of stress from work, I flew in directly to Aspen (which is at ~8,000 feet) and I could have used more time to acclimate, I had some alcohol in the lead-up to the run, and that I drank too much plain water.
In fact, I later learned that my blood sodium level was 118 mEq/L. A normal blood sodium level is between 135 and 145, so my hyponatremia was severe.
Yes, that's hyponatremia alright! Had you suffered from any altitude or hydration issues (inc cramp) in the past?
I'd never suffered from altitude issues in the past, even though I've been at altitudes much higher than 12,500 feet.
I'd had issues with hydration in the past, but never anything as serious as hyponatremia. I've always known I'm a high-volume sweater and that I have very high salt losses (check out my salty face after a run in DC...), so cramping is something that I've dealt with periodically.
But my recent move to Hawaii - which has unrelenting heat and humidity for most of the year - has heightened a lot of these issues.
What were your main takeaways from that experience in the Rockies? What, if anything, did you change about your approach to ultra running after that?
There were many takeaways, but here are a couple...
1. Be prepared for anything when in the wilderness
It seems trite, but of course you never expect to find yourself in an emergency situation until you actually do!
There are things I could have done, things I could have learned in advance, gear I could have carried, all of which might have made for a less harrowing experience. That said, I don't beat myself up about all the "what ifs."
2. Second, life is precious
This is also an overused expression, but being so close to death really made me rethink the way I was living my life. In fact, it was what led me to leave my high-paying, high-prestige (and high-stress) DC job and move to Hawaii to become a civil rights lawyer.
The incident has made me push to do the things today that I previously had said I would do tomorrow. In the past, I would view this as being impulsive, or impatient, or undisciplined, but now I just view it as seeking joy in life today.
That's an awesome silver lining!
Ok, I believe you later suffered your first DNF in a ultramarathon in Hawaii due to cramping, which led to you searching for solutions and coming across Precision Fuel & Hydration. Had you used electrolyte supplements before you tried PH?
Yes, that's right, it was at the Tantalus Triple Trek, a 50K trail race here on Oahu. It did me in. Part of the reason I cramped so severely is that I was definitely pushing myself much harder than I should've been early on in the race.
But another reason is that I likely wasn't taking in enough electrolytes. The twin lessons were to slow down and do better with electrolyte supplementation.
I'm not unfamiliar with electrolyte supplements. I took about 5 salt tabs an hour when I did my first Ironman back in 2006 (when I was a naïve teenager!). But I had never truly been consistent or disciplined in how I addressed my electrolyte situation in training/racing until more recently.
After my first DNF, and with all the other data points I now have, I finally realized that I need to treat hydration as a separate dimension of my nutrition plan. When I pack nutrition for runs now, I think about carrying sufficient calories, water, and electrolytes.
So what PH strengths do you use and when?
As a heavy/salty sweater I use PH 1500, mainly for preloading before a long run and recovery afterwards. What I love about the 1500s is that it makes taking in enough electrolytes super easy. It's delicious stuff and doesn't feel "heavy" (like many other brands do), which makes it perfect for before and after runs.
Glad to hear that! Has your personalized hydration strategy helped reduce the cramps do you think?
Yes, the PH products have been an immensely helpful addition to the "arsenal" of products that I now use to combat the cramps and hydration issues!
Did you try anything else to combat the cramps and did any of those help at all?
Yes, I've tried a number of things. My go-to pre-race meal is Vietnamese pho. The noodles are delicious and easily digestible, but more importantly, the soup broth is both very salty and helps pre-hydrate me too. It's the perfect well-balanced meal.
The most important and impactful change I have made is to think about how to address electrolyte balance 24/7, rather than just during runs. For example, I know how problematic it can be to start a run with an electrolyte deficiency, so I focus on topping up on salts immediately after a run (just as I would do with food and water) so that my body returns to stable levels before my next run. PH 1500 is perfect for this.
I also place salty products (including boxes of PH) in my desk drawer at work, so that I can preload in the late afternoon right before doing my daily evening run.
And at night, I think ahead for the following morning. In fact, as I am typing this up right now at 10pm, I'm sipping on a bottle of PH 1500 as a way to pre-load before my long mountain run tomorrow morning.
Finally, carrying electrolyte pills is no longer optional for me. On any run longer than 90 minutes, I carry a medicine bottle with about 15-20 pills. It's better safe than sorry.
I have run as much as 100 miles and 15,000 vertical feet in a single week of training for my upcoming 100-miler, and I've found there's very little room for error when it comes to having my nutrition completely dialled in...
Indeed! So, what's up next for you in 2019? Have you been back into the Rockies since your incident?
2019 will be a fun year! First up on January 19 is the HURT 100, which is considered one of the toughest trail 100-milers in the world. I'm lucky to live in Honolulu, a stone's throw from the trail system on which the race takes place, so I've been able to train on the brutal course multiple times a week. I can't wait for race day!
In April, I will be part of a 6-person team racing in the 5th edition of The Speed Project, a 340-mile relay race from Los Angeles to Las Vegas. A good chunk of the race runs through Death Valley, so heat training and proper hydration will be crucial.
Finally, although I haven't been back to the Rockies since the incident, I will finally be making my return in September, when I run the 100-miler at Run Rabbit Run in Steamboat Springs, Colorado (with my doctor's approval, of course!).
Aside from these key races, I'll do a handful of other trail races and marathons, and will continue organizing and doing other "runventures," including a Sea-to-Summit-- a run from the ocean to the 10,023-foot summit of Haleakala on Maui.
