Comrades Ultra-Marathon

Megan Dale / Consultant Anaesthetist / NHS Fife

From the Amazon to the Sahara, ultramarathons are becoming more and more popular. However, in South Africa, none are more iconic than the 86km Comrades Ultra-Marathon. This year, Consultant Anaesthetist and distance runner Megan Dale stepped up to the challenge. As well as talking us through her race, Megan gives Adventure Medic an update on Exercise Induced Hyponatraemia (EIH) and tells us why we should all give ultra-running a try.

As we pulled off the M4 into Durban city centre, the traffic was suddenly bumper to bumper. Not an unusual occurrence for the third largest city in South Africa, except that is was 04h30 on a Sunday morning. As the traffic lights turned red and we slowed to a stop, I kissed my husband goodbye, got out of the car and joined thousands of lycra – and singlet-clad individuals making their way to the seeded starting pens that blocked off the main street.

The smell of Deep Heat and other mentholated muscle rubs was overpowering. This got stronger as we all bunched together like sardines. Or perhaps lemmings? The nervous chatter died down the closer we got to the 5h30 start. Thousands of voices joined together for the South African national anthem, and then ‘Shosholoza’. The ‘Chariots of Fire’ theme tune followed suit. The cock crowed. The gun went off precisely at 5:30 and 14,336 runners surged forward marking the start of the Comrades Ultra-marathon. A few minutes later, we passed the first of many distance markers to come: 86 km to go.

Background

The first Comrades Marathon, run in 1921, was the brainchild of war veteran, Vic Clapham. He wanted to find a way to honour the memory of his comrades who had endured hardships and died in during the Great War of 1914-8. With the exception of the World War 2 years, 1941-1945, this race has been run every year since. It is iconic in South Africa. The route is between Durban, on the Natal coast, and Pietermaritzburg, 86 km inland from Durban. The direction alternates each year between the ‘up run’ – from the coast towards Pietermaritzburg with the highest point being 824m above sea level and a total elevation gain of over 650 m – and the ‘down run’.

The Race

In 2013 we were running ‘uphill’. I use the term ‘uphill’ as a euphemism for ten monstrous hills, with a variety of ‘undulations’ in between. Two hours into the race (66 km to go…) and already there were rivulets of sweat running down my arms and legs as the cool morning air warmed up rapidly with the rising sun. I thought it was supposed to be winter in the southern hemisphere? Looking ahead a massive peloton of runners snaked its way up one of the many uphills that characterised this familiar route. You were never running alone. Then someone asked me how I was enjoying my first Comrades:

‘So far so good…I think’. It’s hard to know how to feel with the knowledge that you have to complete two back-to-back standard marathons and a further 2.96 km.

‘Just take it slowly’, he said. ‘Don’t go out too fast. Walk the uphills’. And he slowed down to a brisk walk to illustrate his point as the road sloped upwards, yet again.

I was starting to slow down unintentionally. I had a pacing chart pinned to my shorts, aiming to finish in under 10 hours. I had already fallen well off the pace after 3 hours, a point brought home to me when I was overtaken by the runner in a rhino suit. Oh well.

As I notched up the kilometres at an achingly slow pace, I started to become aware of a few things. Relentless thirst, and my intestines trying to escape from my body, by whichever means possible. So far I had managed one energy gel (a double espresso energy bomb), an energy biscuit containing enough calories to feed a small malnourished country, and two pieces of heavily salted potato wedges. The gut was not happy. As the halfway mark approached (44 km to go…), I could only face fluids. General modesty had deserted most runners a long time ago, as I ran past many urinating by the roadside (at least they were still coordinated enough to aim in the right direction) or those hunched-over, projectile vomiting.

The Heat

The heat was incredible. Oddly, I started to look forward to the next hill as I was now walking up all of them. My strategy after the halfway mark had been to walk up all the hills, and in-between to run for 25 minutes, walk for 5 minutes. The stark reality was that I never made it to a full 25 minutes. I would just slow down to a hobble. Someone asked a police patrol vehicle what the temperature was on their car thermometer. They glanced at the dashboard and said, ‘Er… 22 degrees’, a blatant lie. I later found out it was 32 degrees Celsius. The hot, dry wind that had started at Inchanga hill picked up as we got to Harrison Flats, sweeping red dust across the roads and stinging chafed skin.

I had been holding out for the moment I got to Camperdown (26 km to go…) as this is a mass spectator point where friends and family can cheer on a runner they’re supporting. My spirits picked up as I found the anxious but relieved faces of my husband and parents. We exchanged sweaty hugs and then I was off again, trying not to cry, saying ‘Gotta go, see you soon’. Would it be so bad if I just gave up now, got into their car and left? It was evident that other runners were facing a similar brick wall of low morale. One runner next to me was ranting, ‘I’m done with Comrades! Why would anyone do something so stupid as to run this ridiculous distance? I’m never coming back!’ The colour of her race number was orange, indicating she was a back-to-back runner – having done her first race as the down run the previous year, and now back again the this year for the up run. I had read about these negative runners who can bring you down with their negative energy! I tried to cheer her up: ‘But you managed to finish last year and you’ll get an extra back-to-back medal this year’. She wasn’t buying it. I ran on, past more vomiting, urinating people. How much had they drunk to produce so much urine? I had only been twice and that was hours ago.

Polly Shortts

Someone shouted out ‘We’re down to single digits!’. We had less than 10 km to go. I would have cried but couldn’t spare any more fluid for tears. I continued to ignore the increasingly angry gut. Polly Shortts loomed. I had been reading about this hill. It was a short hill but one of the steepest, coming at a point where we’ve already run almost 80 km. I found out afterwards that even the winner that day had walked up this hill.

During the walk up Polly Shortts, a friendly runner told me he and his wife had had 3 (or was it 5?) failed cycles of IVF. They had now adopted two little girls. He told me not to wait too long before having kids. Another runner lay on his back in the grass by the side of the road, hands behind his head. ‘My friend, you’re not going to finish this race by lying there. Get up!’ another racer chided him.

A very chipper TV journalist, with camera crew and a massive TV screen waited at the top of Polly Shortts, ready to interview the weary. I thought about breaking into a run in case I was caught on camera, but then the thought passed. I’ll just walk a little bit more.

The road gradually descended into Pietermaritzburg. The crowd frenzy was building…4 km…3 km… And suddenly we were entering the cricket grounds. I put on a last burst of speed to beat the Australian runner in front of me. In my mind I was a graceful gazelle, in reality I was hobbling. Any good running form had flown out of the window hours ago. I glanced at the clock as I crossed the finish line: 10 hours 18 minutes 33 seconds. I looked around in stunned disbelief; someone placed a (rather diminutive) medal around my neck. I paused briefly to let through some paramedics carrying an unconscious runner on a stretcher, a stark reminder of how tough this race had been. I used my last ounce of energy to flash a smile for the photographer and staggered off to find my family.

Cheers, fluids and fuels

The Comrades Marathon is the best supported race I have ever taken part in, and that goes for crowd support and refreshments.

Firstly, the crowds. Given that the up run is 86.96 km, crowds line the route for almost 90% of the distance. The course organisers banned participants from listening to music for the participants’ own safety and to encourage individuals to engage in the ‘comradely’ spirit of this event. I confess I was concerned, being very much an habitual iTunes downloader and power song addict. But I soon realised music is superfluous, as the noise from the crowds and music played on loudspeakers by the course organisers, or from a spectator’s car boot, would have drowned out my own playlist. Your name is printed on your number so people can call out to you and this really keeps you going. For many of the Natal population, the Comrades marathon is a great day out. Most spectators have clearly woken up at the same time as the runners: not just to support their own, but to find a prime spot along the route, picnic and barbecue by the roadside, sit in a deck chair with a cold beer (oh, the cruel sight of it!), and cheer. Many folk take it upon themselves to stand at the side with trays of orange segments, or platters of cooked potato pieces, dunked in salt – an absolute godsend! In the heat, local spectators would even turn on their hose pipes to soak passing runners.

The course organisers spare nothing when it comes to providing fuel for the runners. There were 49 sponsored refreshment stations, which works out to one every 2 km, so you are never left thirsty for long. There were sachets of water and Lucozade, paper cups of Pepsi (one of the official Comrades sponsors), bananas, oranges, chocolate, biscuits, jelly babies and cooked salty potatoes.

Exercise Induced Hyponatraemia

Which brings me onto the topic of exercise-induced hyponatraemia (EIH). As a medic this rings close to home. Hyponatraemia is one of the most common medical complications and cause of fatalities in distance running and other endurance events. Two mitigating factors contributing to the rising incidence of this condition is the rising popularity of endurance events and the change in advice given to athletes regarding fluid intake. Prior to the early 1980’s, athletes were advised to avoid drinking during exercise, resulting in hypernatraemia and dehydration. Advice has clearly changed since then, encouraging athletes to consume as much fluid as possible during exercise. Race organisers now provide copious amounts of water and energy drinks.

Pathophysiology and clinical features

The pathophysiology of this condition is not fully understood. It is most likely a combination of excessive water ingestion, which overwhelms the hormonal and renal control mechanisms for plasma sodium levels; defects in hormonal control mechanisms and renal water excretion; probably coupled with excessive sodium losses. Further risk factors include: exercise duration > 4 hours, female gender, low body weight, drinking > 1.5 L/hour during the event, pre-exercise overhydration, abundant available fluids along the way, non-steroidal anti-inflammatory use, and extreme hot or cold environments. The clinical features of this condition often mimic those of dehydration! Athletes can display no/minimal symptoms (weakness, dizziness, headache, nausea and vomiting) to severe symptoms of cerebral oedema with altered mental status, seizures, pulmonary oedema, coma and death.

Prevention

Ideally, prevention is the best course of action, starting with education of the race organisers, medical attendants and the runners themselves. Runners should be encouraged to drink only to thirst and no more than 400-800 mls/hour. Serial weight measurements before, during and after races can give an idea of gain in total body water…but this is not always practical on race day! There is insufficient evidence to support the ingestion of extra sodium as decreasing the risk of hyponatraemia, and this may even lead to complacency about the condition. However, salt ingestion (0.5-0.7 g/L of water) is an appropriate amount to replace sodium lost during sweating.

Treatment

Not all race event medical tents have facilities to measure serum sodium concentrations. The Comrades Ultramarathon is exceptional in that there is a 3 bed, fully equipped ICU-style resuscitation area, staffed by a specialist emergency team, as well as a mini laboratory as treating a collapsed runner can present a diagnostic conundrum without these specialised investigations on-site. Mild hyponatraemia (serum sodium 130-135 mmol/L) can be treated with fluid restriction and observation until spontaneous diuresis occurs. Severe hyponatraemia (<120 mmol/L) or symptomatic hyponatraemia requires hypertonic saline. EIH is usually acute (<48 hours) allowing for rapid and safe correction without developing osmotic demyelination syndrome. All athletes receiving treatment for EIH should be transported to a medical centre where serum electrolytes and urinary sodium and potassium excretion can be observed, and further supportive management of these patients can take place.

My plan

How did I manage my own fluid intake? I tried to minimise drinking pure water. I had electrolyte replacement effervescent tablets in a plastic bag in my pocket (to prevent my own sweat from ‘effervescing’ them!) and popped one into my water bottle, followed by a sachet of water whenever I took one. I alternated this with energy drinks, to get some sugar. I must admit that towards the end of the race, I became a bit uncoordinated with manoeuvring the salt tablets into the bottle and trying to tear open sachets of water…so I just drank Pepsi! I tried to keep a running total of my fluid intake – again simple addition became a real challenge with each passing hour – but it worked out roughly to 500 ml/hour. I also took note of whether my watch strap started becoming tight around my wrist – a simple but effective measure of oedema!

Training for Comrades

Entries for the Comrades Marathon open in September of the previous year, with entries capped at 18,000. The race is usually run on the first Sunday of June. I entered in November, allowing myself a full six months of preparation, starting from a baseline of being able to run a half-marathon comfortably. There are many training programmes available online for an ultra-distance running event – some specifically for the Comrades Marathon and people of different abilities. I used a programme which I downloaded from the Comrades Marathon website, aimed at those wanting to finish within bronze medal time (sub 11 hours). The emphasis of the training is on slowing down and spending time on your feet. The long slow weekend runs are the most valuable part of the training, with shorter, paced runs or time trial runs during the week. Rest is essential to allow recovery and stave off injury. My rest days were Mondays and Fridays. Because of the timing of this event, UK runners will do most of their training in the winter months. There is no room for letting the weather stop you from getting out there! Remember the Scottish adage: there is no such thing as bad weather, just bad clothing!

Runners need to qualify to enter the Comrades Marathon. Any IAAF accredited road race of marathon distance and further can be a qualifying race. You can enter Comrades before having done a qualifying race, as long as you complete the qualifying race and submit the time a month before Comrades. You are seeded according to your qualifying time.

On average, aim to do 2-3 marathon distances and a further two longer runs in the lead up to Comrades, which means looking at the race calendar many months in advance to find suitable races that you can enter at different stages of your training. I entered the Endurance Life Coastal Series Marathon in Northumberland, which takes place in early March. I did my first ultra-marathon two weeks later: a 33 mile (52 km) run in Deeside. I did another marathon towards the end of April and then a further 54 km long run a month before Comrades, going on to taper for the last four weeks.

Not only do you need to train your body, you also need to train your mind. Your perception needs to alter so that marathon distance becomes a training race and hills become an invitation!

Why do this race, or any significant distance?

Why not? Growing up in South Africa, the Comrades Marathon had often fallen on a midweek public holiday and as kids we’d get up early to watch the start and then follow the race on TV on and off during the day. Coming home to run this race was an incredible moment for me. Why run any significant distance? Perhaps to gain some perspective? The modern world is filled with all manner of challenges and hardships, imagined ones and real ones. It is easy to get swept away with in the momentum of a busy life and occasionally you have to take time out to do something physical and primitive to get some grounding. And if you’re in pain, you know you’re alive!

References

1. Rosner MH, Kirven J. Exercise-Associated Hyponatremia. Clin J Am Soc Nephrol 2007: 2; 151-161.
2. Boulter J. Comrades Medical Care. Comrades. The official magazine of the 2013 Comrades Marathon. pg 67.