Hydration, klutziness, and other pre-race thoughts

I need sodium while racing. Worst case scenario, I'm on the course for four hours. Gu gel just isn't going to cut it, I'm told. And I hate Gatorade. I tried the PowerBar Fruit Punch drink, which I found to be decent. I'd rather have the taste of plain water for my hydration, but I know I need the sodium.

The sprained ankle is healing, I guess. It's been 3 and a half weeks, and it's still quite swollen. I can do everything on it -- run, bike swim, weights, etc. At the end of a work day, it does hurt, especially if I'm wearing heels. So I've been a bit lazy and wearing scrubs quite a bit to work.

And speaking of being a klutz, I faceplanted yesterday while running. I tripped on the sidewalk and landed on my right side, scraping up my right knee, hip, and both palms. I got up, shook it off, and ran another 45 minutes. I don't know how often normal people trip and fall while running, but it seems to happen to me about twice a year.

Oh and one other thing... I think my weight is fine at 159 lbs. I don't want to lose any more weight. I don't need to.

All this rambling... can you tell I'm a little nervous?

Sweat Rate

It was suggested that I calculate just how much I sweat in an hour. I decided to do this today, in 104 degree heat, as I rode my bike through Griffith Park up to the Valley.

I weighed myself before. Then, during my hour-long ride, I sucked down two 24-oz bottles of water and a Gu pack. I felt constantly thirsty. Normally the bike provides some air conditioning because you're moving at a decent pace. Not today. I felt hot and awful.

My worry with hydration during a long event, such as the upcoming olympic distance tri, is not only of drinking too little, but possibly of drinking too much. Slower endurance athletes like me are at risk of hyponatremia, a too low sodium concentration in the blood from drinking more fluid than what their body is losing.

Even after drinking so much, I weighed myself -- I had lost a half a pound! In that hour of cycling, I had lost fifty-six ounces of fluid. Almost two liters!

Maybe the moral of the story is to not ride in ridiculous heat like this. But at least now I know that in extreme heat, I sweat a LOT.

The Looming Olympic Distance Tri

After my ankle sprain, I thought seriously about whether or not to keep my spot in the LA Triathlon. My ankle was ridiculously swollen and black and blue. Running on it was painful, so I didn't run for the first week. Even kicking while in the pool hurt.

I changed my goal for the race to endurance, rather than speed. I've done plenty of sprint tris, now for my first olympic distance tri, I just want to finish. I may be DFL (dead f........ last), but I'll finish.

My training hasn't been crazy. I do weights for an hour three days a week with my trainer and then six cardio sessions, about 45 minutes to an hour and a half each. I haven't doubled up on workouts much either, in other words, usually just one workout a day. And I think I'm enjoying my training more that way.

One more week. I'm a little nervous.

Shunsh Kashish

That's Armenian for "Take a deep breath."

English is not the first language of the vast majority of my patients. In fact, more than half of my patients barely speak English. If only I spoke Armenian, the first language of 80% of my patients. Or Spanish. Or Tagalog.

I've developed a small vocabulary of Armenian. Just the medical basics. In chveses -- how are you? Lavay -- good. Tsav unis -- do you have pain? Barke -- lie down. Nustie -- sit up. Batz -- open. Pagai -- close. And a few others.

Pee pee and poop are universal words too.

I really do wish I spoke a second language. I took Latin in high school. Everyone told me how helpful it would be in medicine. What a waste. Don't believe the hype, kids. Learn Spanish.

Another Manipulated Story

I'm listening to the radio this morning, and I hear, "A mother in Phoenix is charged with starving her children. They were on a vegan diet."

Then the news man decides to editorialize, "You know, vegan diets just aren't good for kids."

Ok, who made the news man a nutritional expert? Further, there obviously was something missing from the story. There's a very detailed piece from a Phoenix newspaper here. I'll give you the highlights.

Yes, the family was vegan, but....

- The parents were terrified of childhood obesity.
- They shunned doctors. Their children had never seen a doctor, nor did they have any immunizations.
- The children had epilepsy, and even with that disease the parents would not take the kids to a doctor. Instead, they relied on a homeopathic woman who prescribed herbs.
- One child died of untreated grand mal seizures.
- The family limited the amount of time the kids could eat.

Vegan diets are getting more press and more acceptance. It is still frustrating to see stories like this manipulated to make veganism look irresponsible.

Riblet and Stir Fry

I'm all about preparing what's easy for dinner, as opposed to looking for new and cool recipes. Maybe if I cooked for other people besides myself I'd feel more adventurous. This is something a little interesting, I suppose. There's a Gardenburger Riblet, which is full of protein, and baby broccoli and shitaake mushrooms stir fried in a little canola oil and Soy Vay.

Sprained!

I'm on the disabled list again...

On Sunday, I was playing dodgeball. After hurling the ball at the opposing team, I ran backwards, landed on the outside of my left ankle, and fell to the ground onto my right wrist.

I sat down and iced for a few minutes. Then, bored, I joined back in. It didn't hurt too bad.

Now my wrist and ankle are sore. I'm limping and it hurts even to write.

And I'm supposed to meet with my trainer tomorrow morning.

This better heal fast. I have an olympic distance tri in 4 weeks!

Camp Pendleton Sprint Triathlon

It was a different kind of triathlon -- the first one that I've done that was entirely on a military base. It was also the longest bike in a triathlon that I've ever done -- 30 kilometers or 18.6 miles.

I'm awful on the bike. If I was good enough that I could contend for a medal, then this was the wrong race. But this was my usual performance: do well on the swim, get passed by lots of people on the bike, and pass a few people on the run.

I don't have the official results until Wednesday. But I know that based on the distance of the bike and the huge number of people passing me, this was not a shining race for me.

My next goal is to become better on the bike. I'm going to have my bike fitted, just to make sure that any mechanical issues that are slowing me down are taken care of. In other words, that involves taking my bike to a shop and having it fine-tuned to fit me. I think I need to raise the seat a bit, but I'm not sure. My trainer says he's going to be working with me on a spinning bike too.

Next Triathlon: Camp Pendleton Sprint

My next triathlon is on Saturday.

With all that has passed in my life recently, my training has at times been less of a priority.

My last triathlon was over a month ago. Before that triathlon, I put in all the hours, got in all the workouts, yet didn't do as well as I wanted to. This time around, I've done a few things differently.

I have been working out with a personal trainer three times a week. We do strength training, endurance, stability, and plyometrics. They're tough workouts.

Another experiment: I've lost a few pounds. At my last tri, I was 165 lbs (I'm 5'10"), and now I'm 159 lbs; in other words, my body mass index has dropped from 23.6 to 22.8. Both are well within the range of healthy for my height. But, theoretically, less fat moves faster. My goal is a 17% body fat percentage; at last measurement I had 27% body fat.

I can't wait to see how it all plays out on Saturday at Camp Pendleton.

Going in Peace

I don't share deeply personal stories on this blog. But I want to share this one because of the impact that it has had on me, being the family member of an ill patient rather than the physician.


My grandmother was the healthiest 92 year-old woman I knew. An avid shopper, she walked on the treadmill for 30 minutes every day and went out to dinner with her friends on Saturday night. She lived independently in her own apartment. She looked in on her 88 year-old little sister who lived down the hallway. Until last Thursday.

She was leaving the dining hall when she fell. She hit her head. She was confused. She was emergently taken to the nearby hospital. The CT scan showed "a little bleeding", I was told. Keep in mind that I'm in Los Angeles and my grandmother is in Michigan. She's waking up, my mom says.

The next morning, I'm told she has bleeding in her brainstem, but "they're still not sure" what is going on. But my grandmother was awake and alert, though she had a lot of bruising from the fall. My brother, who also lives in LA, and I booked a flight to leave that night.

The next morning, my brother and I were at my grandmother's side. I could barely recognize her, with the right side of her face drooping and bruised. She opened her left eye when I spoke to her and held her hand; she said my name. Then she said my brother's name.

Shortly after that, she recognized none of us. It became apparent that she was fading. Several doctors came in, none offering much explanation of what had occurred. But their optimism was disturbing. A brainstem bleed in an elderly woman who was clearly getting worse was very very bad. One doctor talked of the possibility of doing an invasive procedure called a transesophageal echocardiogram. The neurologist, when I asked him point blank what my grandmother's prognosis was (I had a pretty good idea, but wanted to hear his thoughts) said, "We'll see in a couple days."

I didn't feel like the doctors were realistic with us. I didn't appreciate the euphemisms and false hope. I wanted them to be more honest about what her prognosis was and not overly optimistic in fear of shocking us.

Then she had periods of apnea -- in other words, she would not breathe for up to forty seconds at a time. The ICU nurse, who took wonderful care of my grandmother, came in and asked what we wanted to do, did we want to consider having my grandmother put on a breathing machine. No, my mother said, my grandmother would not want that, and at that time, with none of her physicians there, we decided to pursue comfort care only -- no more invasive tests, no blood draws, accepting that this is a terminal process.

There were some terrific nurses who cared for my grandmother. But other caregivers were less than great. I overheard that my grandmother's primary physician considered more than two milligrams to be "way too much" morphine. She was grimacing in pain and needed more medicine. A nurse elsewhere refused to increase a morphine drip, insisting wrongly that the hospice physician would not permit more medication.

It's hard sometimes to be a caring family member and a doctor at the same time. The hospice nurse said to me when I was discussing my grandmother's medical status, "Be her granddaughter." But I couldn't just stand by idly and watch -- there were times when my knowledge as a physician led me to speak up. I requested morphine before my grandmother was moved from one bed to another, to cover the pain that the move would involve. When she started to have rattling with her breathing, I requested a scopolamine patch. When her mouth was dry and crusted, I asked the nursing staff to please swab her mouth. Would those things have been done for her comfort if I wasn't standing by? I'm not so sure.

Was I, a cardiologist, intimidating? Did my brother, the attorney, compound that? Perhaps.

My grandmother died in peace early on Tuesday morning. She was comfortable. Of course I am sad, but I know that she didn't linger in pain. She passed away surrounded by those who loved her.

From this experience, I feel more like I can empathize with family members of ill patients. I want to continue to be honest -- at times, I've feared that I'm too honest or too blunt, but that's what my family wanted, not false hope. And I hope I can better think about the details that matter in keeping patients comfortable.

New Toys

I walk into Sports Authority to buy goggles. Fifteen minutes later, I walk out with all this:


A heart rate monitor (upon the recommendation of my new personal trainer), a kickboard, and a pull buoy (keeps your legs afloat while you stroke with your arms, the opposite of a kickboard). Oh yes, and the goggles. They're great. I can get out of the pool and not have big circles around my eyes for the next few hours. Nice soft gaskets.

Tri training is coming along. In anticipation of the olympic distance triathlon in September, I've ramped up my training a bit. I have a personal trainer who I meet with three days a week at 5:30 am. In addition to this, I'm trying to run 3 times, bike 2 times, and swim 2 times each week. Oh yeah, and did I mention I have a job?

Last week, though, I think I really pushed it. It was my first full week of the new personal trainer, who is pretty tough. Then on Saturday, I rode my bike for 27 miles up some seriously killer hills (the most I've been doing is 45-minute to 1 hour spin classes) and on Sunday morning I swam a mile at Manhattan Beach, which is the longest open water swim that I've done yet. When Sunday afternoon came around and I was going to do an easy, 60-minute run, I ran out of steam a little more than halfway through and had to bail. Today I feel better, though.

Mexican Lasagna

I stole this idea from Mary Ruth, my brother's fiancee. Layer tortillas with various toppings -- refried beans, corn, mushrooms, salsa, peppers -- anything! Then bake in the oven. Serve with salsa. My brother was convinced that you can't do this without cheese to help everything stick together, but the refried beans are sufficient to make it work.

Tri'ing in LA

This town is awesome for triathletes!!!

I joined the LA Tri Club. At 1,450 members, they are one of the nation's largest triathlon clubs. They have multiple workouts every day for all levels of triathletes. It's also a great way to meet people. The day after I landed in LA, before I had even moved into my apartment, I swam in the ocean with the group. This morning I biked with the "beginner" cycling group. We traveled 27 miles, up two huge hills, one of which was five miles long. My legs are hurting big time!

People here are more active than anywhere else I've lived. At the beach, it's not just loafing people eating hot dogs. Groups of cyclists gather for rides along the ocean. Runners are everywhere. And under a tree, you might see someone doing push-ups or sit-ups. It's inspiring.

My next race is August 9, an evening Playa Del Run -- 1 kilometer swim and 5k run. After that is the Camp Pendleton sprint triathlon on August 11. Then, I'm doing my FIRST OLYMPIC DISTANCE TRI -- the Los Angeles Triathlon, on September 9.

Today in Cardiology

My blog got a mention in this month's issue of Today in Cardiology!

And here's tonight's dinner: A Garden- burger Breaded Chik'n patty on whole wheat bread, with lettuce and organic Vegenaise (that's an eggless mayonaise -- no cholesterol!)

Cardiologists, any words of wisdom for a just-graduated cardiologist?

Aversion Therapy

I am terrified of open water swims. Especially those with lots of waves. Like the ocean. And, let's just say there's a lot of ocean here in Southern California.

Now, somehow swimming is my best of the three triathlon events (swim, bike, and run). But still I can't keep from panicking. This caused me some serious trouble in the Hyannis Sprint when my panic triggered an asthma attack.

What better way to get used to swimming in the ocean than by throwing myself into the midst of a race? One with big waves and lots of flailing limbs? There's a race series called the Playa Del Run which takes place on several Thursdays. You can swim the one kilometer and then run five kilometers, or you can just swim or just run. As I've never swam a kilometer in open water, let alone a raging ocean, I did only the swim portion.

I lined up with about 120 people to run into the ocean. Off we went with the gun. The waves were BIG!!! I saw people dive right in, under big waves -- which is what you're supposed to do. I still turn myself sideways and hope it doesn't knock me over. After some breaststroke, I start to ease into freestyle. But every time someone knocks me, I get annoyed, look up, and go back into breaststroke.

But, I didn't panic! I just let the crazy people go ahead, and once it was more clear, I eased back into freestyle. Once we were around the first buoy, people spread out, and there were few limbs to crash into. From what I'm told, it was a really choppy day, but I felt okay.

I came out of the water a little tired, though pleased with finishing that distance of a swim, and watched as people ran ahead of me to the transition area for the 5K run.

That day, I couldn't imagine doing a 5K after the swim. I do feel proud of myself that I could not only swim that distance in the open water, but that I was able to do it calmly. My time was okay too.

Next time, I'll swim AND run!!!

Unsettled

Technically, I'm homeless.

I moved out of my Boston apartment over a week ago. My belongings are in a Bekins truck driven by a guy named Buck from Buffalo.

It's been a relaxing week, seeing my parents in Michigan. Now I'm loafing around in California. I should be studying for my radiation and fluoroscopy license exam. But I'm not.

More posts and stuff when I am moved in.... and I can download pics from my camera.

Boot Camp

Just to mix things up a bit, and because I don't have another triathlon in the foreseeable future, I'm taking a few boot camp classes this week. This morning I ran 2.2 miles in 19:45 (9 minutes per mile, not too bad for me on a humid early morning), did 57 push-ups in 2 minutes, and 55 sit-ups in 2 minutes. I'd love to run faster, but I'm content with the others.

The class is 13 weeks long -- I would love to stay for the entire length of the class, since it seems like it's going to be pretty challenging. But, I will be moving to LA. I'm going to try to find something like that there. That would be fun.

Second Tri of the Season

This one was MUCH better than my first this season.

The swim was 0.5 miles on a nice calm inland lake called Lake Chargoggagogmanchaugagoggchaubunagungamaugg, which will herein be referred to as Lake Cha. The start was very crowded -- legs kicking everywhere. I tried to keep moving, but I really like my personal space so all these people kicking me and swimming into me was really ticking me off. My breathing was really off too, and I was starting to get that panicky feeling again. So, briefly, I did the breaststroke, let the crazy people ahead, and once it was less crowded and I had my space, I swam again. I felt better, got into my groove, and finished off the swim. Lake Cha was nice and peaceful, without big waves, which was nice.

When I swim, I've tried to breathe every three strokes like I do when I practice in the pool. But it never works out that way. So, instead, at the suggestion of our tri club run coach, I decided to go with what I felt natural doing -- breathing every two strokes. It worked out well.

The distance from the water to the transition area, where our bikes and other equipment are stored, was long. So, it was a very long-seeming barefoot run in a wetsuit to get my bike.

The bike started off well. People who break the rules annoy me. One person was riding in the middle of the road, very slowly. I suggested to him to get over to the right. Then some woman passed me on the right (which is a huge safety no-no -- when you pass, you pass riders on the left), and was about to try to zig-zag through three riders. So I rode up next to her and said, "If you pass, you need to do it on the left." I don't think she was thrilled to hear from me. And she passed me again. Two miles later, there she was cursing at the side of the road with her bike upside down trying to fix a tire. Karma's gonna bite you, right?

The course got TOUGH!!!! Around mile four, we approached a huge hill. I put my bike in low gear, stood up, and powered through it. Some people walked. Then at the top of the hill, phew, that was tough, and around the corner was ANOTHER HILL, which was similarly steep. And then ANOTHER!!! Whew were my legs tired! Following these hills came a long downhill, steep at times, and my speed got up to 35 mph, which on a bike is damn fast. I hit the brakes at one point, which was good as the pavement went very rapidly from smooth to treacherous and bumpy and flying off the bike at that speed could have been really really bad.

The rest of the bike ride was considerably less hilly. I took it easier, so that my legs wouldn't be worn out on the 3-mile run. My pace on the 12-mile bike was 15.5 miles per hour, nothing to write home about, but faster than I could have done last season on this type of course.

The run flew by. I didn't feel like I was flying, but it went fast. I was breathing hard, but comfortably, unlike the triathlon two weeks ago. I remember catching up to a woman, who looked like she was struggling, and of course I said, "Good job, keep it up." She said, "My legs are so heavy... they hurt!" I looked down at the back of her leg, where our ages are written -- hers is 53. "Look, my mother is younger than you, and I could never see her doing one of these in a million years, so you are awesome! Keep going!" I think that got a chuckle out of her.

So I finished strong. I don't know when my next race will be, but it will likely be four weeks from now, once my bike and belongings arrive safely in LA and I have a better idea what my schedule will be.

PETA's Letter to Michael Moore

Michael Moore's new movie Sicko, which exlores the many flaws of the American health care system is coming out soon. In honor of this, Ingrid Newkirk, president of PETA, took the opportunity to write a letter to Michael Moore. Included in the letter is the following:

...there’s an elephant in the room, and it is you. With all due respect, no one can help but notice that a weighty health issue is affecting you personally. We’d like to help you fix that. Going vegetarian is an easy and life-saving step that people of all economic backgrounds can take in order to become less reliant on the government’s shoddy healthcare system, and it’s something that you and all Americans can benefit from personally.

The letter goes on to make some great points about the health benefits of a vegetarian diet. But, calling Michael Moore an "elephant" and insulting his weight are completely inappropriate. People are sensitive about their weights. Further, this type of language is more likely to infuriate him rather than to convince him to give vegetarianism a chance.

A vegetarian diet is no guarantee that one will be thinner either. While some people have lost weight by going veg, I know plenty of overweight and obese vegetarians as well. And, while I wouldn't consider myself fat, I do have to work to keep the pounds from creeping on.

Would I call any of my patients an "elephant"? No way!

A better tactic would be to congratulate Michael Moore on his movie, and to suggest that vegetarianism is a way to prevent many of the illness that we see today, rather than insulting his weight.

Finding Time to Work Out

Here's how I get the training in. This year I've had one of the most unpredictable schedules. I've been on call literally every other day for the entire year. So, my schedule has had to be flexible for those days when I stay late at work to finish a case, or if I get called in off hours.

I've gotten accustomed to running with my pager, putting my pager on the side of my spinning bike and checking it every few minutes because I know I can't hear it with the booming music, and bringing my pager poolside in case it goes off while I swim.

But, I've managed to fit in triathlon training. In fact, ever since my third year of medical school, ten years ago, I've exercised at least three days a week. Right now in the midst of triathlon season, I average six days a week.

For example, here's what I did this week (and what I plan on doing for the rest of the week):
Monday -- 6:30 am -- Master Swim, 1 hour, 2000 meters
-- 6:00 pm -- Outdoor bike ride with women's group, 21 miles, 1.5 hours
Tuesday -- 6:30 pm -- Speed training run, about 4 miles total, three speed loops of about 0.4 miles each
Wednesday -- 6:30 am -- Master Swim, 1 hour, 2250 meters
Thursday -- 7:15 am -- Tempo run, 50 minutes, about 4.5 miles with 2.5 miles of fairly hard pace running on the Esplanade
-- 6:15 pm -- Spinning class, 45 minutes
Friday -- 6:00 am -- Weights with my personal trainer, 1 hour, followed by a short run if the mood strikes me
Saturday -- DAY OFF (it always feels weird not to work out)
Sunday -- TRIATHLON!!!!!!!!

ADDENDUM -- Even after writing this, I had to change it up. I spent a few hours at the hospital in the middle of the night on Thursday, so Friday became my DAY OFF and my personal trainer was kind enough to train me on Saturday.