Bicycling the Rim Drive Crater Lake National Park and Atrial Fibrillation

I haven’t blogged for a while because we’ve been on vacation in Croatia for two and a half weeks, and of course after being gone for that long I’ve been incredibly busy at work. I am working on along blog entry (actually it’ll be a separate blog) about Croatia, so stay tuned.

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Me During a Brief Rest Stop

In my opinion bicycling around Crater Lake is one of the finest bike rides in the entire United States, and Crater Lake National Park will, from time to time, close of twenty-four of the thirty-three miles of the Rim Drive to allow bicyclists, hikers, and runners to have a relatively car free day. This year they had vehicle free days on two Saturdays: September 20 and 27, and I made time to be there for both days.

Since I live near Crater Lake N. P. I’ve had the opportunity to ride the rim several times, but this year was my first time doing it in permanent atrial fibrillation (and while on a beta blocker). Always a challenging ride under any circumstances, adding a fib and a beta blocker to mix changes things a bit.

Most riders start at the Steel Visitors Center (Park Headquarters) and ride clockwise. The first thing on the agenda is a three mile climb with 650 feet of elevation gain up to the Rim Village. This is actually the steepest hill along the route, but not the most difficult, in my opinion, mostly because the legs are still fresh. It is quite odd to pedal up a climb like that and find a lake at the top. There are several climbs and descents along the thirty-three mile route, and rarely is there any flat road, and the two toughest climbs, in my experience, are in the second half of the ride – the long easy climb to Cloud Cap (where most people stop to sigh and eat their Clif Bar) and the last grind up to Dutton Ridge. I might even say that you only need two gears to ride the rim – whatever you use as your easiest climbing gear and a big gear for coasting downhill.

Elevation varies from 6700 to 7700 above sea level. Personally I don’t have an issue with the elevation at Crater Lake because I’m used to living at higher elevation, but people coming from sea level might feel it.

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Bicycling in Croatia with Margo

To be honest, none of the climbs (going clockwise) are particularly steep, and there is only a total of about 3500 feet of climbing, but the climbs are so long and persistent that it seems like more. The descents can be fast and one could easily go 50 mph down the descent from Cloud Cap, but don’t. The speed limit is 35 mph and there are often surprising potholes encountered once you get up above 40 mph. The vehicle free days are great because you don’t have to worry about cars behind you. One day I was descending at 45 mph, a speed at which the wind in my ears prevents hearing anything, riding right down the middle of the lane, and was passed by a van. I thought, “What’s your hurry, bro? I’m already going 10 mph over the speed limit!”

The scenery is world class and seeing it slowly, up close on a bike, complete with the sounds and the smells is unimaginably beautiful. Being there on a vehicle free day with hundreds of bicyclists from all over Oregon is even better – there is an amazing energy in the air on the vehicle free days.

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Snowshoeing with Libo April 2013

If you are going to ride the rim, especially on a vehicle free day, keep in mind that once you are past the Visitor Center and the Rim Village (basically once you are past the first three miles) there is no water. I’m a heavy sweater so I’ll take three liters on a hot day. Actually along the last big climb there are some little “waterfalls” right along the roadside and I have seen people filling their water bottles there and it is probably fine; but it is definitely not tested and designated as potable water. Also keep in mind that there will be no SAG wagon trailing you so make sure you have the proper gear and tools for changing flat tubes and minor repairs.

As far as riding the rim in a fib while on a beta blocker, well, it is much slower. I was able to ride it but it took me at least an extra hour. I had a triple chainring on my old road bike, and I used to be able to do the entire ride in the middle chainring (except for part of the first climb); but now I am using my easiest gear for most of the climbing (my new bike has compact double, but the gearing is similar). I think I need to be happy with being able to complete the ride without falling to pieces, and quit lamenting my slower speed.

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Photo by Margo

My personal preference, now that I am in a fib, is to keep going and minimize rest stops. It seems every time I stop it’s like starting over again. On the first Saturday I was riding with a group of friends, including my wife Margo (her first time doing the rim ride) and I told them I wouldn’t be stopping much and that they could catch up to me. The last I saw them was at the top of the first climb, and I actually completed the ride a half hour or so ahead of them – they had fun, stopped at the many overlooks, stopped for lunch. I was the tortoise to their hare; slogging up the hills and only stopping a few times.

Another difference is that now that I am on an anticoagulant I brake a lot on the descents. I’m usually the biggest rider in whatever group I’m riding in and consequently the slowest climber that makes up for that by being the fastest descender. No more. Now I think about how descending slowly will help me keep my blood inside my body and I was passed by dozens of riders on each hill. As a matter of fact I kept getting passed by the same groups over and over. They’d pass me on the climb, then I’d pass them at the top of each hill where they’d stop to look at the stunning view of the lake, then they’d pass me on the descent and I’d pass them again at the bottom of the hill where they’d evidently stop to chat. Over and over – sort of fun.

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Skiing with Jan (evidently I’m relying on old photos because I only took one photo for two days of riding around Crater Lake – like I said I don’t stop enough!)

I returned and rode the Rim Drive again the following weekend as well but my friends didn’t accompany me. It was a much cooler, windier day and looked like rain, and they had other plans. I ended up doing the first half and deciding to make it an out and back. I was thinking about the big descent down the other side of Cloud Cap in the heavy wind and thought that might not be the best idea on account of my being anti-coagulated. I learned that riding the rim counter-clockwise is not as safe as riding clockwise. When riding clockwise the lake is to your right; but when riding counterclockwise there was quite often a steep drop off and no shoulder and no guard rail. The drop offs weren’t a thousand feet or anything like that but they were certainly much further than I wanted to go over on my bike so I did the long descents towards the middle of the lane although I pissed off a few drivers I will live to ride again. There is no way I will ever ride the entire rim counterclockwise. Keep in mind that most drivers are looking toward the lake (why wouldn’t they) and if you are between the driver and the lake they are likely to see you. But when riding the other direction there is more risk of being unseen.


Carter Lake Century 2011 (not my video)

Another good time to ride around Crater Lake in the Crater Lake Century. I have never ridden with the organized century (I’ve always been training for something at that time – it’s held in August) but I have been told it is a blast. As far as I know the Rim Drive isn’t closed during the century but there are about 300 riders up there that day. The number of applicants is limited so register early if you want to get in. The century, obviously, involves more than the thirty-three mile Rim Drive and in addition to more climbing from Fort Klamath up to the Park Headquarters, there is some routing around the local farmlands near Fort Klamath to make it an even one hundred miles.

I would love to hear from other bicyclists, especially cyclists dealing with atrial fibrillation. Please feel free to comment below.

Emergency Pack for Trail Running or Mountain Biking While on Anticoagulants (Coumadin, Xarelto, Pradaxa, Plavix)

This article is a work in progress and is only a description of my strategy for the time being. I hope to learn from readers of this blog about how to better plan for a trail debacle.

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Heading out for a trail run on the Pacific Crest Trail

What kinds of things should a person like me, who is dealing with atrial fibrillation and is taking an anticoagulant (I take Pradaxa), carry on a long run in the wilderness? Or during a long mountain bike ride in remote areas?

When the high country in our local wildernesses is not covered with snow, I will generally do runs, nearly every weekend, of anywhere between six to twenty miles. I almost always run alone (except for my trail buddy – Ringo).

Dangerous and a bad idea? Possibly. But this is what I enjoy in life so I don’t plan on stopping any time soon.

The most important piece of equipment is a phone. People complain that everybody is always on their smartphone, and they should NOT be talking on their phones on mountain summits when everybody else is trying to get all Zen-like and self-actualized, and whatever – that’s a different discussion. You certainly don’t even need to have your phone on; but you absolutely should take it with you, and it should be fully charged. The days of getting hopelessly lost and spelling out SOS with rocks hoping a search plane will find you are fading into the past. A smartphone is a GPS and a direct link to help.

I always carry my iPhone in a baggie with my ID and a sheet of paper towel (which I use for unrelated toilet purposes).

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Fully charged and protected from water

Even if there is poor cell phone coverage in your local high mountain or deep canyon wilderness, and a phone call isn’t always possible, I find that a text message can often still be sent. It might take a while but it eventually will be sent, especially if I am moving along a trail.

There is the standard emergency gear that most people take, often called the “ten essentials” which most people carry while in the wilderness. Of course there is truly no such thing as a standard ten essentials and the list of things you carry will vary depending on the season, your skill set, your location, and your past experience.

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My generic survival gear

I got out my little survival kit that I typically carry in the wilderness, and of course not everything is pictured here, and I might not even have all of this stuff with me on any given trip. Naturally I will also have other things like food, gels, electrolytes, a jacket, and plenty of water.

What I found in my default wilderness pack is:

Two knives – a mini-leatherman tool and a standard knife. I will only actually carry one of these.

Two lights – a headlamp and a tiny LED flashlight (one is plenty).

Fire starter – a cigarette lighter, birthday candles, a tampon, and hand sanitizer (which I discovered has completely evaporated).

A space blanket, a compass.

Repair gear (Shoe laces, tenacious tape, dental floss)

Pain pills: Vicoprofen samples – okay they expired in 2000 but I’m guessing they are still good (at least for a placebo effect). Missing: Benadryl for allergies or yellow jacket stings, and I probably should have some of my Pradaxa in case I end up unexpectedly staying out overnight. Also missing: small roll of duct tape, safety pins, and my whistle!

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Saint Christopher Medal

Oh, and there is a Saint Christopher medal. This one belonged to my grandfather. Well it probably won’t change anything, but it certainly couldn’t hurt. Feel free to substitute your own personal good luck charm.

But what about specific items for the runner on an anticoagulant? Is there anything else beyond the “ten essentials”?

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Other stuff: Map with reading glasses (if needed) and some rope

Obviously having a major bleed while running alone in the wilderness would be a disaster. Death is certainly a possibility. How can a trail runner prepare to increase the odds of a good outcome?

I always make sure to let somebody know (usually my wife) where I’m going and I also send her a text (I text “OOTW” short for “out of the woods”) when I get back to my vehicle.

I also wear a Road ID. This way if somebody finds me they will know I am on an anticoagulant. Maybe this won’t help, but it certainly is worth wearing. At least they will be able to figure out why I bled out so quickly (I know – not funny).

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My Road ID

Another item I always carry is a bandanna. This can be used for a number of purposes, such as making a field dressing; but I want to have it in case I need a tourniquet. Plus – I have an extra one because my trail dog always has one draped around his neck.

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Bandanna

My bandanna came in handy a week ago when my wife Margo (not on an anticoagulant) crashed her mountain bike and punctured her left thigh with her brake lever. I used it to make a compressive dressing before we road our bikes back to where we could get a ride to the hospital.

One item I do not currently have but definitely need to obtain is a Quickclot field dressing. Evidently these things really work and are routinely used in combat situations. It is a topical coagulant (an anti-anti-coagulant?) which helps clot blood and also serves as a physical barrier to bleeding. I’ve been meaning to obtain one of these for a long time. They are available online via amazon.com, and I just ordered one.

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Quickclot

Question: Will the Quickclot sponge even work on bleeding in an individual who is on a direct thrombin inhibitor like Pradaxa? Answer: I have no idea. I’ll let you know if I ever get a chance to find out.

In case of bleeding the most important first step is to apply direct pressure. As a surgeon I have a lot of experience with this. Usually sixty seconds of direct thumb pressure will stop or slow most bleeding, but of course if you take an anticoagulant it will take longer. Apply direct pressure as long as necessary. Elevate the wound if possible. Don’t try to clean out major wounds as this will restart bleeding – that can be done later at the hospital.

A tourniquet is a last resort, but the bandanna can be used as a compressive dressing if needed.

Please understand that an anticoagulant doesn’t completely stop clotting of blood, it just makes it take longer. Eventually bleeding will stop. Hopefully before all the blood leaves your body!

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Ringo always has a spare bandanna for me

Bonus – How to stop a nosebleed:

I have been plagued by frequent nosebleeds since I was a child but, oddly enough, I haven’t had a single nosebleed since I started Pradaxa a couple of years ago. The best method I have found is to pinch the nose, fairly tightly, just above the nostrils, and lean forward. Don’t lie with your head back – that doesn’t work. Hold for a full sixty seconds. Repeat as necessary.

If you are, like me, a trail runner or mountain biker on an anticoagulant, I would love to hear from you. Please leave comments and suggestions in the comments area below.

Thanks.

Atrial Fibrillation News Update

Here are a few internet news stories related to atrial fibrillation. In the future I’ll try to update more frequently so I don’t end up with four topics in one blog entry.

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Overall, the increase in risk of heart attack was about 70% in AF patients, even after accounting for other cardiovascular disease risk factors, such as hypertension, high cholesterol, body mass index, and history of stroke and vascular disease. However, when the researchers looked at subgroups, they found that increased risk of heart attack was more than doubled in women and African Americans with AF—but less than 50% for men and whites with AF.

I’m not sure what to say about this – hopefully runners with atrial fibrillation (who hopefully also have other heart healthy lifestyle choices – like a healthy diet, not smoking, reasonable body weight) will do better than the general population. One bit of good news – the blood thinners a fib patients take to prevent stroke also seem to help prevent heart attacks.

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“Novel” anticoagulants refers to the newer prescription anticoagulants that are used as an alternative to Coumadin (warfarin). Specifically: Pradaxa (which is the one I currently take), Xarelto, and Eliquis.

I can tell you that as a clinician there are not many things more frustrating than prescribing medications for people who are on Coumadin – it seems like it interacts with everything! One of the great things about the newer anticoagulants is that they have less drug interactions – but they still do have potential drug interactions.

Please click on the link to see tables for drug interactions involving Pradaxa (Dabigatran), Xarelto (Rivaroxaban), and Eliquis (Apixaban).

Obviously all of the novel anticoagulants can interact with any other drug that is *ALSO* an anticoagulant – like Plavix or aspirin. Keep in mind that this includes NSAIDs like Alleve (naproxen), Motrin (ibuprofen), etc.

Personally, I completely avoid taking ibuprofen and naproxen – but every once in a while (like after a brutal long run) I will take a Celebrex. Tylenol (Acetaminophen) is fine – no interactions with the anticoagulants (although it has its own issues).

By the way – if you read the article and see a possible drug interaction please don’t stop taking any of your meds – but contact your own doctor immediately for advice.

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A recent study has shown that Coumadin (warfarin) actually increases the risk of stroke for people in atrial fibrillation during the FIRST THIRTY DAYS of warfarin therapy. That’s just the first thirty days – the idea is to prevent having a stroke, and that’s what taking Coumadin does.

This finding does not suggest that anything will change – doctors are still going to put people on warfarin to prevent stroke. They just have to get through the first thirty days!

If you are on warfarin and you read this article – please do not stop taking your medication.

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Finally – the FDA has not yet approved the Watchman left atrial appendage closure device by Boston Scientific – but it has given a “vote of confidence.” It appears that this gadget, which is implanted in the left atrium to prevent the formation of the clots that cause strokes, may be approved by the FDA for the US market late this year. The majority of the panel agreed that the Watchman was equivalent to standard treatment with warfarin, but it hasn’t been compared to the new novel anticoagulants (see above).

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Atrial Fibrillation Stroke Calculator

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Atrial Fibrillation Stroke Calculator

I saw this link today on Facebook and thought I would share it – it is an AF Stroke Risk Calculator, and was posted by the Atrial Fibrillation Association – a great resource for people with atrial fibrillation. As you probably know one of the greatest risks of being afflicted with atrial fibrillation is that it can lead to you having a stroke. Blood clots can form in the malfunctioning atrium, break loose, travel to the brain and – BOOM!!!! – you’ve had a stroke. Prevention is the best approach.

This calculator is basically a clever automated version of the CHADS2 score. I was delighted to find my risk is 0%.

But if course my risk is definitely higher than zero percent – even if my CHADS2 score is zero.

My heart is abnormal in more ways than the atrial fibrillation. I have hypertrophy of my left ventricle (from running – not a risk factor) but I also have “severe hypertrophy” of my left atrium (the top chamber of the heart) which my cardiologist assures me is a risk factor for stroke and although my CHADS2 remains zero I am on an anticoagulant (Pradaxa).

My question has been: Why not include left atrial hypertrophy in the CHADS2 calculation?

Answer: I dunno.

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Lillian and Lolawanda ready for another trail run

My other question has been: What else can I do to reduce my risk of a stroke?

I understand my risk is NOT zero, regardless of what this calculator says.

Obviously one thing I know I can do is to remember to take my Pradaxa twice daily. Believe me, for somebody who is only taking one medication it isn’t as easy to remember as you might think. I have considered switching to Xarelto simply because of the once a day dosing.

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My Pradaxa

But other than that what else can I do? One more thing (I think) – stay well hydrated.

As a large, slow, long distance runner (who is often on the trail for several hours at a time) I sweat more than smaller runners, and I have to be very careful not to become dehydrated. I spoke with a friend of mine who is an Internists/hospitalist and he agreed – don’t become dehydrated. Being dehydrated can literally thicken the blood and increase the chance on a clot, and therefore increase the chance of a stroke.

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Be Careful Out There!

How much water should a person drink? I have no specific prescription but what I do is try to drink enough so that my urine is relatively clear once per day. Also there is such a thing as too much water and big, middle-aged distance runners are at relatively high risk of hyponatremia (too much water – not enough sodium) so be careful out there!

We talked about other risk factors are there? Risk factors for blood clots in the legs include being inactive, obesity, and smoking – probably less likely for the readers of this blog.

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Sedentary after a LONG RUN

What about alcohol? Does that increase the risk? He said probably not and in moderation might even decrease the risk – but remember – alcohol clearly increases your risk of atrial fibrillation – and if you drink enough alcohol you will become dehydrated – so there you go!

By the way – don’t expect this this risk calculator or this blog to advise you as to whether or not you should take your aspirin, your warfarin (Coumadin), your Xarelto, or your Pradaxa. It is important that you make this decision with your doctor.

Pacific Crest Trail on Atrial Fibrillation?

I live near the Pacific Crest Trail. The famous, fabled, fabulous PCT. Just about twenty-five miles away. You can look out our back window and stare lovingly at the mountains where it courses through the Sky Lakes Wilderness.

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Heading out to run on the PCT

Although I come off in this blog as a marathoner, or an ultrarunner, what I really enjoy more than anything is trail running (and mountain biking – but mountain biking is forbidden on the PCT so forget about that). I simply love trail running and hiking, especially in the local Sky Lakes Wilderness and Mountain Lakes Wilderness; and the best part of being at my level of fitness and health is being able spend a weekend day doing a ten, fifteen, or even a twenty mile trail run. Although it is a slog now because of the atrial fibrillation I still love it – I love the movement through the wilderness and I love the trail itself.

Usually the only one who goes with me is my little trail dog – Ringo.

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Ringo on the PCT at Brown Mountain

At this time of year – late Summer – all the thru-hikers, or I should say the small percentage that have made it this far, are coming through Southern Oregon. Most thru-hikers are traveling from South to North; they start at the Mexican border and hike through California, Oregon, and Washington with the goal of reaching the Canadian border. There are a lot of hazards along the way that can cause hikers to drop out and fail to finish – including blisters, running out of money, running out of time, deep snow, diarrhea, boredom, and forest fires.

I try to spend time on the PCT this time of year and will often photograph thru-hikers and post the photos on my flickr page.

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PCT Thru-hikers

In addition to trail running on the PCT I am also an “armchair traveler,” meaning I’ve read a bunch of books about thru-hiking the PCT, including:

Cactus Eaters by Dan White – probably the best written PCT book and my most recent read.
Cascade Summer by Bob Welch – a middle aged Oregon newspaper writer hiked just the Oregon section. This might be more my speed.
Wild by Cheryl Strayed – the most well known and popular PCT book that will undoubtedly get more people on the trail. Also a well written and engaging read.
A Blistered Kind of Love by Angela Ballard – fascinating dual journal by a couple thru-hiking the PCT. It was interesting how the different genders report their trail experience. The male writes about where they went and what they did, and the woman writes about how she feels.
Skywalker – Highs and Lows on the Pacific Crest Trail by Bill Walker – the most endearing and charming PCT book ever.
Pacific Crest Trail Hiker’s Handbook by Ray Jardine – groundbreaking and controversial – Ray clearly changed the way people approach long distance hiking.
A Long Walk by Hap Vectorline – a whimsical journal of a partial through hike that started at the Canadian border and made it as far as Oregon.
In addition to the books I read various PCT blogs, and many of the youtube videos as well.

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Hikers

My dream is to someday thru-hike the PCT – but I don’t think it will ever happen for a number of reasons. I’m certainly in good enough shape, and strong enough, but at 53 am I too old? I don’t think so – I’ve met plenty of thru-hikers that were middle-aged. They tell me they are slower and have to leave earlier and hike longer to keep up – but that would be no problem. I think hiking for that long on anticoagulants might be an issue. On Pradaxa falling just isn’t what it used to be! The main problem is, of course, finding the time. I work full time and just don’t have the resources to take six months off from work.

Maybe some day I could just thru-hike the Oregon section. Or maybe just the Sky Lakes Wilderness (fifty-one miles) – that could be done in a weekend. Why not?

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Ringo Dingo

But I still love running in the Sky Lakes Wilderness. As far as falling out on the trail and bleeding out, or having a stroke out there, or being eaten by a bear, or whatever, I like to say that I’d rather die in the Sky Lakes Wilderness than in the Sky Lakes Medical Center.*

*Our local hospital, where I am on the surgical staff, is the Sky Lakes Medical Center. I like our hospital – I’m just saying that I’d prefer to die with my sneakers on, so to speak.

Running and Mountain Biking with Atrial Fibrillation? Get a Road I.D.

I used the see the Road I.D. commercials while watching the Tour de France and think, “Why would anybody buy a thing like that?” That was before I went into persistent atrial fibrillation and started taking a potent anticoagulant (Pradaxa).

Now something as ordinary and routine as falling down on a trail run or crashing on a mountain bike can become a big deal – maybe even a life and death situation.

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My Road I.D. has my name, year of birth, hometown, my wife’s number and my sister’s number. Also it indicates that I am in Atrial Fibrillation, have no drug allergies, and am taking Pradaxa – an anticoagulant.

This way if I am found dead they know who I am and who to call to come pick up the bike and the body. If I’m still alive they will know about the atrial fibrillation and the anticoagulant. Pradaxa doesn’t have a reversal agent but any medical personnel will know to watch for bleeding and start an IV to push fluids. It certainly couldn’t hurt.

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Wearing my Road I.D. at a pizza parlor

I wear mine whenever I ride or run, and also whenever I drive. I take it off at work.

I was half joking when I said “if I’m found dead” but somebody (I can’t recall who) recently noticed my Road I.D. and said he wished his friend (brother-in-law?) had had one. Evidently he had gone out for a run and died out there (for whatever reason) and had no identification. Nobody knew who he was so they put the body in the morgue for the weekend. I seem to recall that the wife was out of town and they had a hard time figuring out who he was. Eventually when they started to figure out who he was and one of his children had to come from out of town to identify the body. I wish I could remember the details more clearly – but at any rate a Road I.D. wristband would simplify a situation like that.

There’s nothing special or unique about a Road I.D. – any medical alert bracelet would be fine; but a Road I.D. just seems cooler. It’s durable, comes in cool colors, and is highly customizable, it cleans up well when worn in the post work out shower, and goes on and off easily.

Mountain Biking and Atrial Fibrillation

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Mountain Biking in Oregon – Waldo Lake Trail

I’ve just returned from a nearly three-hour long mountain bike ride, so I thought it would be a good time to write about mountain biking while in persistent atrial fibrillation (this discussion is pertaining specifically to persistent A fib meaning I am always in atrial fibrillation and don’t ever expect to NOT be in a fib; I think people who have episodes of paroxysmal atrial fibrillation are going to have a different result).

One of my main concerns when I was first verified to have persistent atrial fibrillation was whether or not would be able to continue mountain biking. I started road riding in the early 80s, back when I still lived in the Midwest. When I moved to Klamath Falls, Oregon in 1987 I began mountain biking. This is a great place to ride, and we have a terrific trail system at Moore Park, as well as a couple of local high mountain singletrack trails that are legal for mountain biking (Brown Mountain Trail, Rye Spur Trail). I feel real connection to these trails and have been riding some of them for over twenty-five years.

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Rye Spur Trail, Klamath County, Oregon

I didn’t use to run is much as I do now, and back in the late 80s and early 90s I would pretty much mountain bike five or six days per week. I have developed some good bike handling skills, especially since in the early days there was no front or rear suspension, and nobody really knew what they were doing anyway. We pretty much plunged our quick release seat posts down into the frame, switched to granny gear as soon as we hit dirt, and would (inappropriately) lock up our back wheels and skid down steep hills – very much discouraged in this modern era. But that’s the way it was – skills develop over time.

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One of my old mountain bikes

At any rate I have developed good skills – skills specific to these particular trails, seeing that I generally know every rock and anticipate every little drop off.

There are two issues with mountain biking and atrial fibrillation. The first, obviously, is that my cardiac output is reduced by about 15 or 20%, so naturally I am a little bit slower. People get slower when they get older, too, so there’s that to deal with as well. But the real issue, I think, is the fact that I am on a potent anticoagulant – Pradaxa. One of the disadvantages of Pradaxa is that it works really well (but the real disadvantages that it does not have a reversal agent). Clearly – there is a risk of bleeding associated with crashing your mountain bike on the trail.

I sort of doubt whether Coumadin is that much safer than Pradaxa as far as this is concerned – while it is true that there is a reversal agent for Coumadin, what is the likelihood that, if I had a major crash, I would be able to get to the emergency department in time for them to give me the reversal agent? I generally ride alone, and our trails are pretty remote. It would take a while for me to get out of there, especially if I was bleeding all over the place, or even worse, if I were bleeding into the space previously occupied by important parts of my brain.

Over the years my skills have improved and my style has changed quite a bit. At age 53 I’m no longer much of a daredevil (I never really was). Back when I was thirty and was riding about five days per week, I estimated that I had one minor crash per week, and usually one major crash per season. In all that time I think I’ve only actually hit my head once (I definitely recall a bleeding ear after crashing on a technical descent on a trail called Garbage – never liked that trail).

I have always felt that all of your instincts and reflexes are directed toward protecting the head. It’s automatic.

Of course I have worn a helmet when bicycling since 1983. I even bought a new helmet when I went into atrial fibrillation and started anticoagulation. It fits better than my old one and it’s florescent green, so hopefully I have less chance of being run over by a pickup truck.

The only time I have ever had a significant bleeding problem while mountain biking was back in 1990. I came off the trail ride and was heading around the paved road at Moore Park to the picnic area to get some water when some young guys in a pickup shouted at me, “Wrong way, dude!” I didn’t yell back at them, but I turned around and glared at them as I zipped down a little hill to the picnic area, giving them a look that said, “You talkin’ to me?” I was going pretty fast at that point and hit a speed bump that sent me skidding across the pavement for a while.

I bet those guys were impressed.

Anyway, I had a lot of road rash, was just goes with bicycling to a certain extent, but the worst thing was I had a “degloving injury” on the side of my abdomen. What that means is that part of my skin more or less stuck to the pavement while the rest of me kept moving and the skin was pulled away from the underlying tissue. It didn’t break all the way through the skin, but I developed a hematoma the size of a baseball right where the “love handle” would normally be. Twenty-three years later it’s actually still there to a certain extent, not the blood, but a big lump of scar tissue beneath the skin, and the skin over that area is still kind of numb.

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Klamath Ridgeview Trail – Moore Park

That happened with no anticoagulation – I never even took an aspirin back then. If I had a similar injury now that would’ve been a major hematoma – I might even need a transfusion.

That’s the risk. Falls are part of riding a mountain bike. I’ve been on Pradaxa for a year now and I think I’ve only had two crashes. I am so much more cautious than I used to be that I rarely ever crash, and when I do crash it usually something stupid like having mud or ice in my pedals and not been able to click out when stopping, falling over like Artie Johnson used to do on that tricycle on Rowan and Martin’s Laugh In. I honestly can’t say that I’ve noticed more bruising or bleeding than I would expect prior to Pradaxa. So far, so good.

I feel it is important, however, that when you’re cardiologist tells you that you probably shouldn’t be mountain biking that you do what he says. Don’t be like me. Don’t disregard your cardiologist advice. Do as I say, not as I do.

All joking aside – there is a certain risk and if you can accept that level of risk, then continue mountain biking. If not, stay off the trails.

As far as how much persistent atrial fibrillation affects my climbing, well, when I first get started it is quite difficult. After I warm up it really doesn’t seem like it’s any different than not be in atrial fibrillation. Recall that I do not take anything like a beta blocker or an antiarrhythmic – if you take medications like that your experience may definitely be different. All I take is the anticoagulant.

I’m slow, definitely slower than I was twenty-five years ago, but it almost seems like it’s within the realm of what you’d expect from being that much older. Like I said in the article about running in atrial fibrillation, it’s almost like you’re a pickup truck with a four speed manual transmission, but you can only use second and third gear. But you can still have a lot of fun in those two gears! It just takes a while to warm up.

Personally I think road biking is more dangerous than mountain biking, as far as bleeding risks are concerned. All my best crashes have been on pavement, including my best mountain bike crashes (see above). And pavement is usually where cars, driven by people who are talking or texting on smart-phones, hit you.

As far as endurance and energy output are concerned road biking, by its very nature, is easier to do in persistent atrial fibrillation that mountain biking. On a road bike you get into a groove, and have a certain steady energy output. That’s perfect for atrial fibrillation. Anybody who trail rides, especially on technical, steep trails, can tell you that mountain biking consists of a little burst of energy here, then a little short, brief period of rest and recovery here (by slow pedaling for a couple of seconds), and then hammering the pedals again to get over the next little obstacle, or whatever. That’s what’s fun about it – it’s almost like doing a puzzle. Trail riding involves a lot of little, short, anaerobic bursts of energy – and of course atrial fibrillation has diminished this ability, as far as I’m concerned.

Although, speaking strictly of endurance, I don’t think that is changed too much since I went into persistent atrial fibrillation. I can still ride for just as long as I used to be able to ride. I have found that while I have lost speed with age I have gained endurance in spite of atrial fibrillation.

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Moore Park Mountain Bike Trails

I am very interested in other mountain bikers’ experiences with atrial fibrillation, especially athletes who take rate control or anti-arrhythmic medications. Please feel free to leave comments – Thanks!

On Being Slow – Running with Atrial Fibrillation

Being in persistent atrial fibrillation is sort of like being a pickup truck with a four speed manual transmission, but you can only use second and third gear.

If you’re going to continue distance running in persistent atrial fibrillation you’d better expect to be slower.

I was already slow to begin with – my quickest marathon was four hours and forty minutes and it took me an hour to run a 10K. I’ve always avoided 5Ks because people in 5Ks simply run too fast. Once I was a back of the middle of the pack runner, well, now I’m truly a back of the pack runner.

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Training Run

I’ve always been a larger runner, and that’s definitely a factor in being slow. I’ve done a dozen marathons at over 6′ 3” and about 235 pounds, and have often felt that people would “mark” me, use me sort of as a target. I’ve felt particularly self-conscious about those people, often found in the back of the pack in a marathon, who will run up and pass me and then start walking – over and over again. This can be really annoying. One guy did that for 14 miles! I finally told him, “please either keep running or keep walking.” I know that these people are simply followers of Jeff Galloway (there are a lot of them in the back of a marathon pack), but it’s still annoying and it happens every race.

But if I was moderately slow before, I’m silly slow now. In an effort to preserve my pace I have actually lost about 40 pounds – but I don’t think I’ve even broken even. I had previously ran ten minute miles in shorter training runs, but now twelve minute miles are more common. As stated previously I had a cardioversion and was in sinus rhythm for thirty-three days – and at my new weight I was delighted to be able to train, for shorter runs, at a nine minute mile if I wanted to – but alas after a quick five-mile run in the thirty-third day I went back into persistent atrial fibrillation. I could feel it immediately and knew what had happened.

I imagine that a lot of athletes who are reading this blog are people who have had episodes of atrial fibrillation, or who go in and out of atrial fibrillation. I think people with intermittent atrial fibrillation become much more symptomatic and have a lot more trouble with training. They might not be able to train at all. But with persistent atrial fibrillation, at least in my experience, I have found that I stabilized and am able to train (a slower pace). You just have to get used to it.

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Back of the Pack – Haulin Aspen Trail Marathon and 1/2 Marathon

There are a few major differences, however. Prior to atrial fibrillation, like most runners, I would start out a long run at a fairly quick pace and more or less degrade as far as my pace was concerned as the miles accumulated. But with atrial fibrillation I actually start out quite slow, and after a mile or two find that I have picked up the pace quite a bit. I generally don’t do much interval training, but I imagine that is out of the question at this point. I live and train in the mountains and I can still run hills, but not really very quickly. When bicycling I find I don’t stand up and charge up hills any longer, but remain seated and spin more.

Being in persistent atrial fibrillation is sort of like being a pickup truck with a four speed manual transmission, but you can only use second and third gear. You start out pathetically slow, and your top speed is greatly diminished – but she can still drive as far as you want.

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Big Slow Runner – Before A Fib

The most important thing, of course, is that I am still able to continue trail running and mountain biking, and I am still able to participate in marathons and even ultra marathons. I still get to experience the sheer joy of slogging through a long trail run through the forest. I was never going to win any prizes to begin with, so what’s the difference?

Actually, I was delighted to get a medal for second place in my age group at the 2012 Bizz Johnson 50K, which I ran while in persistent atrial fibrillation. That was the first year they had a 50K at that event and there weren’t very many participants. I’m pretty sure that there were only two people in my age group, but still!

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Second Place (age group) Hell Yeah!!!!

One good thing about ultra running and marathon running, especially compared to 5Ks, for example, is that nobody really cares if you are slow. I was surprised that there were many people who finished behind me when I ran my first 50K in atrial fibrillation. Although it is kind of embarrassing to be so slow, you just have to change your mindset, and when you get involved with ultra sports, especially with atrial fibrillation, you need to simply enjoy yourself, enjoy the run, enjoy the trail, enjoy the people, and not worry about time.

If there are any other athletes reading this who are in persistent a fib, or intermittent a fib, I would love to hear about your experiences, and I encourage you to leave comments.

Running Alone

Even before I was in persistent atrial fibrillation I generally would like to run alone, although occasionally I run with my wife, Margo. Bike riding was different – I would often go for mountain bike or road rides with friends. At this point, however, I generally go alone so I can just keep my own slow pace.

Ninety-five percent of the running that I do is trail running, and almost all that is done with my dogs – so technically I don’t run alone. They don’t care how slow we go – they are simply glad to be out there.

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Ringo on Mount McLoughlin

Ringo is a blue healer, border collie cross and is a great trail dog. He behaves well off leash, never chases anything, and always stays with me. There are a couple of races around here that allow dogs and he always gets to go along for these events.

Our other dog, Sophie, is a husky/shepherd cross and pretty much needs to be on leash 100% of the time (otherwise she runs off after God knows what), which can be challenging for trail running. It pretty much completely eliminates Sophie as a mountain biking partner.

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Running at Lake of the Woods with Margo, Ringo, and Sophie

I often run in wilderness areas, or even remote trails near town, and sometimes worry about having a fall and getting hurt on the trail. I guess that just has to be an acceptable risk. I like to say I’d rather die in Sky Lakes Wilderness (our local wilderness) than at Sky Lakes Medical Center (our local hospital – where I am on the surgical staff) – but I feel sorry for they people who find me – imagine finding somebody on the trail . . . that big and that dead! As a precaution I always like to tell my wife where I’m going, and of course, I always have my cell phone with me. I usually take a bandanna along so I have something I can use for a tourniquet if necessary – don’t forget I am on a potent anticoagulant (Pradaxa).

I’d be interested in hearing from other runners and mountain bikers who are training while on anticoagulants and find out what type of precautions you take. Please feel free to leave a comment.

Heat and Salt and A Fib

As stated previously I get pretty lightheaded when I get up from a sitting position after a hard workout, particularly in hot weather. Orthostatic hypotension. I don’t know why I get dehydrated so easily now, but I have learned that I need to eat something salty and drink a lot of water  after a workout, particularly a run or a bike ride which is longer than an hour or two, otherwise I get pretty dizzy when I first standup, and I’ve had a friend who is an nephrologist and another friend who is an internist both tell me to make sure I drink plenty of water after a workout and get some salt. Just one more fun aspect of being in persistent atrial fibrillation.

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Pre-Race Motel

This is the first time in my life I’ve ever actually been trying to get more salt. Most people spend their lives trying to avoid salt. I have started bringing potato chips for a post run snack to the trailhead for my long runs. Another great post run snack is some blue corn chips with some hummus with some Hoisin sauce.

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Pre-Race

Although it is neither here nor there, I’d like to state that I am a vegetarian (nearly vegan – if not for the occasional veggie pizza) as far as diet is concerned.

I also find that I am more sensitive to heat, which is obviously related. Last summer I would often start to feel pretty tired 17 miles into a 20 mile training run. In cool weather a 20 mile trail run is no problem. When I’m training for a 50K I basically try to do a 20 mile run every weekend.

Fortunately I live in Klamath Falls, on the East side of the Cascades of Oregon, where we have relatively cold Winters and generally cool Spring and Autumn. Summer, obviously, can be pretty hot – but nothing like Southern California, Arizona, Mexico, the South, etc.

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Resting During a Trail Run

I have also noticed over the past several years that I did quite poorly during marathons if the weather got hot. The concept of hot weather is a relative term – for me anything over 70°F (21°C) would be considered hot. My ideal running weather would be 35 to 55°F. Ten years ago I could do a 20 mile run when it was 90°F (32°C) without much problem. Those days are over.

I’d be interested in hearing from other people with atrial fibrillation with respect to this. Please comment.

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Ringo – Pooped Out After a Long Trail Run