Addendum (7/5/2007)
I was irresponsible in using terminology with no explanation, especially after pointing some people here who would not be expected to know the diabetes lingo! So here's a brief glossary, in no particular order:
BG: blood glucose, or blood sugar. The alternate acronym, "BS," is nice to use on occasion, especially when one is frustrated. BG in the US is measured in mg glucose per deciliter blood (mg/dL);
Dexcom: glucose meter that displays subcutaneous glucose concentration, updated every 5 minutes. It works well a lot of the time, but is not reliable enough to replace a BG meter (yet!);
Animas pump/insulin pump: an infusion pump that delivers insulin continuously. I use an Animas brand pump because it is waterproof and delivers insulin in really tiny amounts;
Basal rate: the rate of background insulin delivery. Insulin is needed 24/7;
Bolus: like an insulin injection, but from a pump. Boluses are generally used for meals and to correct (lower) blood sugar. Insulin is measured in units, "U"; 1 mL = 100 U;
Humalog insulin: the type of insulin that I use. Its activity peaks within an hour but it starts working in 5-10 minutes; it also stops working after around 2.5-3.5 hours for me (usually). Insulin causes the blood sugar to leave the blood and go into fat and muscle cells.
Race day arrives!
The sun rises early in Coeur d'Alene this time of year, but I beat the sun this Sunday when I got up a few minutes before 4 AM. I had slept well but was not amused by a reading of 419 on my BG meter. I took an 8-unit correction plus breakfast bolus, more than I was comfortable with, but necessary, I thought, since I was technically still in taper mode with elevated insulin needs. I switched to my race day basal insulin profile and finished some last-minute preparations before eating my breakfast of oatmeal, peanut butter, a banana and soy milk. I had practiced this breakfast and bolus the day before (and a few other times) and noticed that mixing the peanut butter in the hot oatmeal, as advised by my nutritionist, really does slow the absorption down significantly. About 20 minutes later, my BG was down to 333 and it continued to fall slowly but steadily until about 6 AM, when it started rising slowly.
Swim Start
Meanwhile, we headed down to the race start, where over 2200 anxious athletes and their fans were milling about. I waited to have my bike tires pumped up to their "race psi" of 120--pretty measly given the options out there--and stocked my bike with fluids and my new velcro-coated BG meter. We found a spot in the crowd for me to get my wetsuit on when I realized I had forgotten to put Bodyglide in my bag. There was absolutely no way I would swim 2.4 miles without it, so, with about 30 minutes to go, I ran back to my T1 bag and quickly covered my neck, arms, and calves. Before we knew it, it was time to go to the race start. I checked my BG one last time and it was on a slow rise and very high at 295. I took 0.2 units of Humalog and ate a Hammergel and a GU for a total of 47 g carb's. Looking back, I both underbolused plus overate given my rising BG's. I guess I was afraid that the choppier conditions would cause a larger drop in BG; the dose would have been appropriate during training when I wasn't in taper mode, and didn't eat anything before swimming. One of my biggest fears is dropping low on the swim because I have such a hard time recognizing it, plus it would put me out of commission for at least 15 minutes.
With minutes to go before the start of the swim, the announcer said that race officials had determined the conditions to be severe enough that they would make the swim portion of the race optional, and that any competitor would have the option of doing a duathlon instead. Well, this was not a good thing to hear. Of course we would all try the swim but it was unnerving to hear that they considered the conditions to be so bad. Looking at the water, I decided that it wasn't much worse than the previous few days, and that I would definitely at least try to get through it. I wasn't really sure what was going to happen though.
I lined up to the very left of the crowd with a few minutes to go. As soon as the canon went off, the front masses dove into the water; I waited about 10 seconds to let most of them go, and then calmly entered. The water was, indeed, choppy and my breathing was agitated and uneven. After getting into deeper water, I was able to get into a better breathing pattern and to get a feel for the waves. I tried to focus on my swimming and on feeling myself move through the water, as opposed to being annoyed that I was getting tossed around. The sighting techniques we practiced were helpful, and I found that the swimmers around me were friendlier than in previous races. With the mass start, the really fast and/or aggressive swimmers start towards the front and stay in front, unlike in races with multiple starts, where I tend to get clobbered as each wave passes by me.
I rounded the first corner and made the left turn towards the third point of the rectangular course. Instead of swimming straight into the chop and moderate swells, I was now swimming tangential to them and found this to be somewhat more comfortable. After rounding the 3rd corner, I checked my watch: 32 minutes. Phew! I knew it would be a quicker swim back and felt relieved that I would make the swim cutoff. I finished my first lap in 54 minutes and hopped out of the water. My friend was supposed to be there but was nowhere to be seen. I looked frantically for several minutes and asked everyone if they had any spare GU, but was told no. How could this be?? We had everything arranged. I ate both gels in somewhat of a panic and waited for about 4 minutes, looking around constantly.
A volunteer asked me if I wanted to pull out of the swim but I said "No!" and got back into the water. I was mad! Did someone not let him in? I was also scared. Was my blood sugar low? What would happen if I needed a gel? (I had eaten both of those stuffed in my sleeves.) Would my blood sugar fall too low? As I was thinking these thoughts, I passed over a scuba-diver sitting on the lake bottom. Why was he there? To take video? No camera... To look for drowning swimmers?? I needed to chill out. I tried to concentrate on my swim and reasoned that I did feel okay and that my BG was very likely not low. After a few minutes, I got back into a rhythm, and felt that the second lap was much smoother than the first. After rounding the 3rd corner again, I saw that I would make it back in plenty of time. Very relieved, I exited the water in 1:55 and ran past my hysterically happy family & friends, who knew that I had been concerned. It was an amazing sight to see them there, cheering me on.To the bike!
After running up from the swim I was met by the "peeler" volunteers who strip off the wetsuits. This is perhaps one of the finest features of an Ironman race--no need to akwardly yank the wetsuit off of my feet. The peelers sat me down on my back, pulled the westuit off, pulled me up, and handed me my wetsuit and T1 bag and I was on my way to the women's change tent. Here I quickly slipped on my bike shorts and tested my BG--380! Ugh! Over the next 15 minutes, I took 1.5 U to correct and avoided eating anything. I was really hoping to avoid this situation. At least I wasn't as upset about it since I had encountered the same thing at Wildflower in May. Still, I was not happy. I started the bike, feeling pretty fresh, although concerned about my BG. Thirty minutes into the ride, I took another 1.0 unit of insulin. About an hour after the swim my BG was at 377 and I took a very small sip of Perpetuem. I also started my extended bolus of 2 units over 5 hours (which I ended up canceling after 3.5 hours). Thirty minutes later my BG was up to 393; I took another 0.5 units and checked almost 20 minutes later to see that my BG had continued to rise to a shocking 418. I was getting mad and a little worried. I had some backup insulin + a syringe in my pocket, but really didn't want to stop to pull it out. I switched to a backup infusion site that I had placed the day before, just in case something was wrong. I was getting hungry but waited to eat until I saw that I was clearly falling with a BG of 321 two hours after starting the bike. In another 30 minutes, my BG fell to 224, where it hovered for at least another 75 minutes before making a soft landing around 145. With about 2 hours to go on the bike, I started using the Dexcom exclusively since it was working very accurately.
The course itself is beautiful, and I enjoyed the portions next to Lake Coeur d'Alene and through the area of Hayden. Not too difficult, it reminded me of riding through Marin County, with lots of rolling hills. There are a few substantial climbs but none over 1/2 mile long, I would guess. Also, there are enough flat or moderate downhill stretches to use aerobars; although some others complained that they would have liked more. We had temperatures in the 60's and some slight headwinds--it was a perfect day for a Bay Area triathlete.I felt happy and strong during the first lap, and tried to think of the whole day as a celebration of all of the hard work we had done. I tried to keep my heart rate in zone 2 (aerobic) and it was hovering pretty close to the top. For the second lap, I backed off and kept it closer to lower- to mid-zone 2. I tried to avoid thinking about it too much, but running a marathon was still in the back of my mind.
The special needs bags were available at mile 64, and I swapped out my Perpetuem for a new bottle, which I had frozen the night before in a styrofoam cooler filled with dry ice (which I was surprised to find at the local Safeway). I ate maybe 2 pretzels but grabbed the Fig Newtons and enjoyed those over the next hour. I asked the volunteer to save my bag, since I had a spare infusion set and partially full vial of test strips in it; sadly, though, I never was able to retrieve it after the race.
Finishing up the ride, I saw my family madly cheering me on, little kids raised in the air. The end of the ride is mostly downhill, with a short out and back before finishing up. How could I not smile with these three cheering me on? (Note the excellent T-shirts.)
And now a marathon...I quickly changed back into tri shorts and got ready for the run. I was happy to start running at 4:19 PM, and was hopeful that I could finish the race by 9 or 9:30. My BG was 115 and the Dexcom was working well. My insulin was as follows: 3:08 PM (still on bike) pump off; 4:08 PM basal rate 0.05 U/hr; 4:38 PM pump off. Between 3:30 PM and 5:23 PM my BG was slowly declining, even though I continued to eat every half hour or so. My biggest concern for the race was keeping my blood sugar up during the run; I had encountered rapid onset of hypoglycemia at the beginning of training runs after long rides (bricks), and during long runs after a heavy day of training. I felt strong and comfortable for the first 7 miles with splits of 9:45, 9:49 (picture taken after this split I think), 9:55, 11:11 (bathroom break), 9:41, 9:51, 10:35.
Running along the lake around mile 6, I felt hot and started to wonder if I was drinking enough. My 16 ounces of Heed had only lasted me 4 miles instead of half of the run. I was drinking water but trying to avoid Gatorade Endurance, which had given me some GI discomfort in training. I also supplemented with 2 Enduralyte caps during the first hour or so of the race. I had eaten about 2 gels by the 7th mile of the race. Approaching the only substantial hill of the run, I felt a little spaced out, reminiscent of low blood sugar; however, my BG was still around 110 and holding steady. My coach's chart on dehydration flashed across my mind and I remembered that disorientation was somewhere along the path to coma and death. My legs seemed somehow disconnected from my brain and I was starting to envision being scooped up off the side of the road. I passed the aid station at mile 9 and ran another 50 feet before turning around. I felt like I could continue but wasn't sure I would make it to the next aid station. My best shot at finishing was to stop and assess what was going on.I spoke with the medic who asked me when I stopped sweating. My skin was dry, and I assumed at that point that I was dehydrated, but wasn't sure. From my frequent stops at the portapotties, I seemed to be overhydrated, and the dry air in Idaho would probably cause my sweat to evaporate quickly. Still, I had felt quite warm running around the lake's edge, and figured I could have also gotten dehydrated by high BGs in the morning. I wasn't sure if it was possible to make up for that during the course of the bike, or while continuing to run. My BG was 160 when I stopped, high but not alarmingly so; I took a 0.05 U correction. For some reason, the Dexcom also died at this point. When I noticed that it took me over 15 seconds to respond to the medic's questions, I figured I had done the right thing by stopping. Watching runners pass me by, and my sub-5 hour marathon time slip away, I was disappointed. Ten minutes passed, and I got up to try and start running again. Nope. I sat on a large boulder for a few minutes before trying again. Nope. I thought that my race was over at this point and saw my finish slipping away. My muscles still felt strong but I did not have the energy to make my brain and body work together. My good friend James ran by, looking strong and fresh, and gave me some encouragement. Another doctor stopped by and asked me if my urine smelled sweet, and whether I could be ketotic. Well, hardly anything smells sweet in a portapotty, so I wasn't sure. But he was onto something. I realized my pump was still off and that my BG had started to rise pretty quickly before I stopped. In 11 minutes since stopping, it had risen to 176. Looking back, it was rising at a rate of approximately 100 mg/dL/hour. I turned my pump on to the preset basal rate of 0.05 U/hr (and took a 0.1 U bolus 30 minutes later).
Thirty minutes or so after stopping, I started running again, and was surprised to feel that the miles were passing by quickly. The slower pace of this marathon compared to others I have run was more comfortable for my legs, but I felt bloated and could hardly choke down the cola I felt I needed to drink. (Eating solid food was out of the question after mile 15 or so, which is when I started drinking cola.)
I turned back from the lake-front through the neighborhood streets and was given my glow-in-the-dark necklace; I had neglected to put reflectors on my clothes since I somehow convinced myself I would finish before sunset. I had only 2-3 or so miles to go and I could hear the roar of the finish line in the distance. Finally I rounded the last turn before the finish and was greeted by my aunt, no doubt happy to see me alive and feeling much better than after the first lap. My mom was waiting by the finish, she said, and I picked up the pace to finish off the race. I was happy to see that there were still people cheering at the end, and I made my way to the finish chute. I felt strong and gave it all I had, hoping to give the crowds something to cheer about. There was the finish tape and I ran through it, into the arms of several "catchers." I had done it!! Excited, but exhausted, and apparently a little spaced out, I saw the medal being placed around my neck and was happy to receive a congratulatory hug; "How nice," I thought. Only a week later did I find out my coach (who had, incidentally, also raced that day) had been the one to do that.The Aftermath
I felt pretty good immediately after the race, and wondered why my "catcher" was so concerned about keeping me warm with my foil blanket. I had my finisher picture taken and moved out of the area. A good friend and coach (who had also raced!) met me there, and guided me to the massage area and medical area. I was starting to feel really bad, and wasn't sure whether I would be able to make it back to the hotel. I couldn't stomach any food but did start to feel better when I finally nibbled on a slice of pizza an hour later. The BG's were actually quite high and I only had one low BG the morning following the race. Actually, I have had to more than double my daily dose of insulin since the race ended. I am eager to get back to exercising and will do so more fully as soon as my energy levels seem closer to normal.
What I realized after the race is that the Ironman was a one-day event, and that any number of things could have gone wrong. I feel like the day was more of a celebration of all of the training and hard work that it took me to make it to the start. And whether I finished or not--and this was a possibility at any point--the improvements in health and in lessons learned would not be lost.
Still, I was very happy to have finished! (See below.) Thanks everyone for your support--most especially my coaches and diabetes team, unbelievably patient coworkers, and neglected family and friends.
Since my laptop seems to have died, I am sitting here at the hotel computer, bike helmet on, ready to go for one last 10-15 minute ride before I turn in the bike tomorrow. The race begins 7 AM Sunday at the beach pictured here at Lake Coeur d'Alene. Conditions look great except for the swim. The water has been very choppy and is expected to remain so through the race. After two swim sessions, I am feeling more confident, and will be happy to get out in anything less than the swim time cutoff (which is 2:30).
