Broken Ironman

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Today we will talk about Ironman. No, not the superhero in the Avenger movie series. I am not also pertaining to the men who do most of the laundry and ironing of clothes at home, though that’s what I consider the real superhero.

the real Ironman

What I want to discuss is the Ironman, the sports competition. This is a triathlon, or a multi-sport endurance race that includes swimming, biking and running.

There are different version of the triathlon. The shortest is the sprint triathlon which includes 750 meter swim, 21.2 km bike ride, and 5 km run. Then there’s the World Triathlon version which is 2 km swim, 80 km bike ride and 20 km run. But the most taxing of all triathlon is the Ironman. This entails 3.8 km (2.4 miles) swim, 180 km (112 miles) of biking, and then running a full marathon of 42.2 km (26.2 miles). This really takes a lot of strength, endurance, and above all, steel determination.

I have not tried to compete in a triathlon before, because first of all, I don’t know how to swim, or at least swim efficiently. I can bike and I can run. But I have not even finished a full marathon. I have only run half marathon before, and I have run a few. I know how much training that already entails, so I have so much respect on these people who compete in the Ironman.

Last week our city, Des Moines, hosted the Ironman competition. It was hot that day with temperature in the 90’s Fahrenheit. Three competitors in that race landed in our ICU that we have to care for.

You might have guessed that the cause of their hospitalization was due to heat exhaustion. It was not. Then maybe you’ll guess they became dehydrated. Again, that’s not it. In fact, it was the opposite of lack of hydration. They were admitted because they drank too much water. What?!

All three of the Ironman competitors that were admitted to our ICU suffered from hyponatremia.

What is hyponatremia? It is a state wherein the concentration of sodium in the blood is dangerously low. There could be many reasons for hyponatremia, like kidney and heart failure, or derangement of hormones, or certain medications. But one reason that can cause this state is drinking too much water. Plain water that is.

When we are sweating a lot, like when we are doing any strenuous activity or during a very hot day, we do not lose only water but also electrolytes in our sweat, like sodium and chloride, which is salt. So it is important that we just don’t keep up with drinking water but on fluid solutions that has electrolytes or salt to replace them. Another electrolyte that is needed to be repleted is potassium. Many sports drink like Gatorade and Propel are water infused with these electrolytes.

The story for the three hospitalized Ironman athletes were all the same. I know these were highly trained athletes and they should have known better, but for some reason they didn’t like the taste of the Gatorade that was available or the one being given at the course of the event, so they stayed with just water. Since they knew it was hot, they kept up with their hydration with plain water. Without realizing it, their blood sodium level became dangerously low.

What are the effects of hyponatremia? The low serum sodium causes the water to be pushed inside the cells causing swelling of the cells. The most dangerous possible effect is brain swelling. The symptoms include extreme fatigue, muscle weakness, cramps, nausea, vomiting, headache, confusion, seizures and even coma. If the sodium level get critically low, it can be life threatening, and thus needed to be corrected promptly.

And what is the treatment for hyponatremia? You guess it right, salt! So we infuse salt water or sodium chloride solution into the bloodstream. However you want to correct it in the exact way, not too fast and definitely not overshoot it, for that is equivalently dangerous causing permanent brain damage, a condition called osmotic demyelination syndrome. This is the reason critically low hyponatremia needed to be treated in the ICU setting.

Among the three of our Ironman patients, one even managed to finished the whole course, but he became confused a couple of hours later. Two did not finished, though both of them were already doing the running phase, and one was even 3 miles away from the finish line when he collapsed. So close and yet so far.

competitors in Ironman collapsing in the finish line (photo by Joe Jaszewski)

All of them made a prompt and full recovery though. Two were discharged after 2 days in the ICU, while one lingered for a day longer. No permanent damage, just slightly wounded ego. However all of them said that they would participate in the Ironman again. Such a steely resolve indeed, for they are not Ironmen for nothing.

So what broke these Ironmen? Like water can corrode metal, water broke these Ironmen.

(*photos taken from the web)


  1. Thank you very much, doc for this enlightening piece. If I may ask, I have been walking about an hour daily since the pandemic started and have lost 30 lbs. Because I feel lighter, I started running a few hundred meters in my daily walking routine and felt the runners’ high again (used to run when in my 20’s, i’m now 57). I perspire a lot which i find so good. But I noticed every lap (1 mile) i take a leak. Is that normal? I plan to join a 5k run but now thinking how i can run that long if i have to go to toilet once or twice… thank you po.

    1. That’s very good that you’re considering to join a 5K run. The short answer for the need to pee while running is that it could be normal. Perhaps you’re really drinking a lot of water to replace your sweat loss, and your kidney is responding appropriately. Sometimes, older folks can have hyperactive bladder that can be made more pronounce when we exercise. Then there’s also research data that runners, especially older ones, can have a higher release of natriuretic proteins by their body when they exercise which make them pee more. I will still encourage you to do the 5K. I hope that they provide portable toilets in the course of the run (which the organizers usually do). And plus I read that elite marathoners even just pee in their shorts, as they don’t want to stop and lose time, but I don’t think I’ll recommend that. Go have fun running!

  2. Oh my gosh! Glad they’re okay na. There’s next time to redeem that slightly wounded ego. 🙂

    Thanks for the medical explanation! I’ll keep this in mind for my next half-marathon in August.

    1. All of our patients were not first-timers. One of them, this was his 7th. Have fun running the half-marathon. If you don’t like the taste of Gatorade, coconut water is a great alternative with plenty of those electrolytes.

  3. Doc,
    I’ve completed 2 half ironmans which is the 70.3 and yes those athletes should have packed something with electrolytes instead of straight up water. You stated that you can’t swim. That was my weakness before getting into the triathalon scene but I did learn a technique called the “immersion technique” which helps you to swim in any open water without expending too much energy. The person who invented the technique is “Terry Laughlin” who passed away a couple years ago from battling cancer. There are a lot of videos that teach the technique. Maybe you can learn it and eventually sign up for a spring triathalon and maybe do a longer one after.

    Your fellow kababayan,

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