Exertional Heat Stoke - My Story

The original version of this story was originally written for publication on the Korey Stringer Institute website. Many of the stories shared there did not have happy endings and helped demonstrate the severity of heat stroke.

REVISED: April 29, 2022

Background

I had started running in April 2011 to lose weight at the age of 27. I had not been slim and fit since a very young age, but during university I had a lot of extra pounds. I can't say I was inactive, because I would participate in various activities - ball hockey, judo, etc - but at my best I still weighed 240lbs. After getting ACL reconstruction in January of 2010 my weight had ballooned to a peak of 275-280 pounds. I'd been trying the gym and took off a little weight, but it wasn't enjoyable.

I began running with short distances, building up capability using a 3.8KM loop of a lake near my workplace. Over the next year and a half, I would drop to just under 200 pounds. Developing a faster pace and tackling longer distances.

In Newfoundland and Labrador, Canada, the most significant race is The Tely 10. It’s the third oldest road race in Canada, and one of the oldest in North America, having been first run in 1922. It’s a 10 mile race, traditionally run on the 3rd Sunday of July every year. It’s a fast course; largely downhill or flat.

This race is pushed heavily in the media and by local running clubs/fitness groups as motivation to get out and get active. As the snow clears off each spring, numerous 8-12 week training programs are available locally as a kick in the butt to get people active. Participation in this event significantly eclipses that of any other local road race as it has truly become a 'community event.'

I first ran the Tely 10 in 2012, it was my first time participating in an organized road race. I recorded a time of 81:35, far surpassing my goal of 90 minutes. After that I became a regular in local road races, really motivating myself to push hard and obtain new PBs. I ran the 2013 Tely 10 in 73:56.

2014 Tely 10

When 2014 came around, I started thinking about breaking 70 minutes as my goal (under a 4:21/KM (7:00/mile) pace). I can’t say I had adjusted anything in my training for this goal, I just did what I always did, run a lot and push hard, especially in the races. I did not set out specifically to do aerobic or tempo training, hill training, no planned recovery periods, just ran hard; I'd learn later on in life how to train properly. I had not really changed my diet since initially losing weight, so despite running more, I had gained a little, floating between 205-210 pounds.

There is a 5 mile road race 2 weeks prior, often used a predictor for the Tely 10, it's a similar course profile, the local guidance is to multiply your time in that event by two and add two minutes. This event showed I was just outside of the pace I needed for my Tely 10 goal. Naively, it had me confident that 70 minutes would be hard, but attainable. I’ve always had a stronger second half, not settling into a race until a couple kilometers into it (would learn later to go warmups before racing). Based on my time, I figured I could improve enough in a the second 5 miles to hit 70 minutes. I would just push myself to it.

The week of the race was warm, and a trend that would peak on race day. Newfoundland is not particularly known for nice weather, so it was a change of pace from what I had been running in. We typically only have a handful of days in the year that approach 30 degrees Celsius (86 F). If you are warm here it’s because of humidity. 2014 was above average in terms of quality weather for June/July. I was the never the biggest fan of overly warm days. I like to run with my dog, so these days where it was really warm, I typically waited until late in the evening or nighttime to run.

The day before, it was looking like the temperature would be above 25 C (77 F). This made me nervous. I was worrying about how it would impact my goal. I was aware I’d need to hydrate more. I was cracking jokes about either hitting my goal or needing IV and an oxygen mask. It was the first time I ever completed the medical contact information on the back of the race bib; I just had a weird feeling.

On race day, as we arrived by bus to the start line at 7:20am, with the humidex it was already feeling like above 25 C (77 F) in the warm wide open area where the race begins. It was definitely warmer than most local runners were accustomed to. Here, you train yourself to be able to run in wind and rain, not heat. The biggest investment is in cold weather gear. Just walking around the staging areas and race corals, it was really warm.

The Race (July 27 - Sunday)

At 8am the gun went off. I had heard someone comments that it was up to 27 C (81 F). I started strong, focused on trying to avoid getting caught up in the start of race adrenaline rush. Remembering to run my own race. I was keeping a pretty solid pace around 4:25/km (7:06/mile), right where I wanted to be. I recall thinking a mile and a half in that my feet were absolutely burning. Heat was radiating up through the asphalt as well as hitting the racers from above. My heart rate was already up around 170bpm. This was not unusual for me, I’ve always participated in sports, but I’ve never been athletic. I always just aimed to play the hardest to make up for not being skilled.

I had a cup having a cup of water and possibly Gatorade the first two water stations. The sun was getting higher in the sky and it was getting warmer. I took chilled sponges from spectators along the route, and additional water. I hit the 5 mile mark at about 35:49, a 4:27/km (7:09/mile), with my heart rate averaging around 175bpm. I had been hoping for 35:30 at the low end of the halfway point, but still thought it was possible to make up the time. I would just push through, and deliver a negative split.

At around 6.3 miles, there was another water stop. It was here I decided I could not keep up the pace for my sub-70 goal, my HR was staying above 180bpm. I took a walk break, took in water and Gatorade. After about a minute and a half of walking/light jogging, I decided to still give it my best effort. I took off in a full run again, taking my pace down to about 4:32-35/km (7:18-23 per mile).

The Breaking Point

At this time, I recall just feeling exhausted and drained, but determined to force my way through. Focusing on keeping one leg in front of the other and staying on pace. I remember completing one of the steeper inclines on the route. I remember getting a drink from either a water station or spectators. Shortly after this my memory is blank. Looking at my Garmin reports, this was around 7.6 miles. It was a flat part of the course, but my pace took a took a dip for about 45 seconds. My heart rate was at 184 bpm.

From this point on my Garmin stats are much more inconsistent. And my memory is non-existent. My pace was all over the place, ranging from 4:15/km (6:50/mile) to 6:00/km (9:39/mile), my heart rate was steadily in the 180s.

People who know me, recall yelling out and cheering me on, but I failed to acknowledge them. Around the 8.3 mile mark I passed a friend who always watches. She always takes a picture to send to my wife (Jill) at the finish line, just to give her a heads up that I’m getting close. I’ll usually wave and smile, I just ran on this time. A video exist from a checkpoint along the route. It shows me up right and running, passing other racers, and seemingly looking okay. At 9.13 miles, my pace suddenly drops to 11:51/km (19:04/mile) for a few moments and recovers. Very shortly after it drops again.

At 9.3 miles there is fire station. This is where my race ended. It was at 9:10am, 70 minutes after the start of race.

Fire stations along the route typically set up hoses on race day to allow runners to cool themselves. The firemen also provide first aid support. Later on, I would speak with one of the firefighters to try to learn what he remembered as I reached the station.

He recalled seeing me zigzagging across the road. Instantly becoming aware that I was in distress. As I approached the fire station, I headed straight towards the water hose. According to his account, I sat myself down under the stream of water. They came over to check on me. He recalls placing his hand on my shoulder and feeling my heart beating rapidly, it was still over 180 bpm.

They lifted me off the ground - I was dead weight - and sat me on a chair. They started cooling me with more water. Attempts to get a response via trapezius pinches and sternum rubs received no reaction. My eyes were open, I was breathing on my own, sitting up on my own, but otherwise zombie-like. An ambulance was dispatched.

I was taken to the St. Claire’s Hospital, which was along the race route, just over a ½ mile back. I was admitted to the ER at 9:49am. My body temperature was 40.3 C (104.54 F), I was still unresponsive. Immediately I was placed in ice and a cold mist was applied.

Per reports, I remained highly agitated and aggressive into the afternoon, I was rapidly breathing and shivering. Tests to that point showed signs of kidney trouble, and significant liver issues. This caused them to make the decision to intubate me in the late afternoon, I was placed in the intensive care unit (ICU).

In a diary she kept, Jill notes that in the evening my temperature was still at 39.8 C (103.64 F). They wanted to take me for a CT Scan, but needed my temp to be below 38 C (100.4 F). When I was able to get a CT Scan it revealed no obvious sign of brain injury which was relief to my family and friends.

By midnight my temp was finally at 34.2 C (93.56 F).

Race Day + 1 (July 28 - Monday)

The next morning my temperature was back up to 38.8 C (101.84 F). There was a struggle all day to keep it down. I was under sedation, but kept getting agitated. Despite the my high body temperature, my body kept on shivering, this kept driving my temperature up near 40.0 C (104 F) mark once again. They continued to sedate me to combat this.

Blood work was not significantly changed from the prior day. At night my temperature was at 37.5 C (99.50 F).

Race Day + 2 (July 29 - Tuesday)

The doctors attempt to wake me from sedation for the first time. Jill recalls me trying to move my legs.

I had an ultrasound that revealed the presence of blood clots. I had of bilateral posterior tibial vein thrombosis in both legs. Additionally, I had developed pneumonia.

A Helical CT of my head was performed. It revealed no intracranial damage.

All seemed steady throughout the evening until the Doctors told Jill that I was in critical condition. I went into liver failure. Blood work showed my AST levels* were 1,754 units/litre, well above a normal range of 40 units/litre. Doctors remained confident due to my age that I would bounce back, but it created some tense moments among my family, friends, and co-workers.

*Aspartate transferase (AST) is an enzyme that exists in your liver, heart, brain, pancreas, kidneys, muscles and many tissues in your body. Although it can be found throughout your body, AST is most commonly associated with liver health.

Race Day + 3 (July 30 - Wednesday)

In the morning I was more stable. There were attempts to wake me, but I did not respond. Signs of pneumonia on my lungs were confirmed with a chest x-ray.

My AST level hit a peak of 3,123 units/litre.

There was going concern by the medical staff about my unresponsiveness.

Race Day + 4 (July 31 - Thursday)

While I still did not wake up, I was agitated. They fully sedated me again. However, in her diary Jill says I did respond to the sound of her voice.

My AST levels had gone down slightly to 2,833 units/litre.

The pneumonia had not worsened, so that was some good news.

Race Day + 5 (August 1 - Friday)

When Jill arrived the next morning, she was called into the ICU on her own. The nurse told her to speak to me, when she did, I responded, but with difficulty. Eventually, I responded to questions by nodding and squeezing. This was a massive relief to everyone. I don't recall any of this. Drugs are a hell of a thing.

My temp did climb again, floating around 38 C (100.4 F). That evening I was put under light sedation, just to conserve energy.

My AST levels were down to 839 units/litre. Doctors were happy the with the numbers.

Race Day + 6 (August 2 - Saturday)

Once again, when Jill arrived, I was awake. I was still running a slight fever. They restricted visitors and kept me resting.

Later that day, when Jill was allowed to visit again, I was sat up, without a tube in. She recalls being so happy, that she couldn’t cry. I asked questions apparently, but once again I don’t recall any of this.

At night, the fatigue of the day caused a slight fever once again. According to Jill I was confused and disoriented.

Race Day + 7 (August 3 - Sunday)

This morning, Jill is awoken by a phone call. It’s me. I was conscious and asked a nurse to call Jill. From this point on I’m not longer sedated. I can recall parts of the questions and conversations we had on this day. Family and doctors explained what had happened, it was my first time hearing the words "heat stroke".

Race Day + 8 (August 4 - Monday)

I was finally moved out of ICU and into a private room. It seemed like I’m on my way to recovery, I remember thinking that I’d be discharged in a day or two. I'd soon learn this was naïve thinking, as the battle was still to come.

Race Day + 10 (August 6 - Wednesday)

That morning while the Doctor is examining me, I indicated that I felt stiff and sore. I had assumed this was due to lying down for so long, but decided it I should note the feeling. He was instantly concerned. In no time there is blood work completed and I was hooked up to a potassium chloride IV. I had been diagnosed with rhabdomyolysis*. My CK levels** had spiked to 19,187 units/litre (U/L), normal levels may range from 22 to 198 U/L. Higher amounts are a sign of acute muscle injury.

The Doctor explained the risks, how high levels of fluid are needed to help prevent kidney damage caused by the high CK levels. I would remain on this IV regiment until the day I was discharged. I learned later that in the first couple of days in ICU, that my CK and other levels all returned to a more acceptable range, so they were not monitored so closely. The sudden increase in CK levels was a surprise. At 5pm on Race Day it had been at 983 U/L, a tenth of current levels.

The status of the blood clots was evaluated. It was had moved from the calf veins into the popliteal veins in both legs.

*Rhabdomyolysis is a potentially life-threatening syndrome resulting from the breakdown of skeletal muscle fibers with leakage of muscle contents into the circulation. The most common causes are crush injury, overexertion, alcohol abuse and certain medicines and toxic substances.

**Creatine Kinase is a type of protein. The muscle cells in your body need CK to function. Levels of CK can rise after a heart attack, skeletal muscle injury, or strenuous exercise. Elevations in CK levels are frequently classified as mild, moderate, or severe. These classifications roughly correspond to less than 10 times the upper limit of normal (or 2,000 U/L), 10 to 50 times the upper limit of normal (or 2,000 U/L to 10,000 U/L), and greater than 50 times the upper limit of normal (or greater than 10,000 U/L), respectively. The risk of renal failure increases above 5,000 to 6,000 U/L. Higher CK levels are associated with greater burden on the kidneys, causing acute renal failure, severe electrolyte abnormalities, and acid base disturbances, resulting in significant morbidity.

Race Day + 12 (August 8 - Friday)

My CK levels hit their peak, 31,330 U/L. Doctors were quite concerned, but the primary treatment is to pump the IV and monitor the levels and other organs for issues. With 4+ litres of IV going through me a day, I certainly kept people busy emptying the pee jug.

I had an abdominal ultrasound performed. The examination revealed no abnormalities; my internal organs appeared to be functioning properly, despite the concern shown by blood work levels.

I began very light physio therapy, it was a big milestone. Learning how to stand again and getting the used to balancing was extremely fatiguing. I was amazed at how much my body had deteriorated in such a short time.

Race Day + 17 (August 13 - Wednesday)

I was examined by a Rheumatologist. He was following up on the elevated CK levels. He had checked to ensure there was no underlying conditions, particularly autoimmune diseases that would have triggered the significant increases. This is something I'd be checked again for later in the process of looking for answers on what happened.

Physiotherapy had progressed to the point where I was able to walk a lap around the floor with the assistance of a walker and Jill. It was exhausting and slow, but a great accomplishment to be able to leave the hospital room. It was also extremely humbling, to go from running 16 kilometers to barely doing 100 meters around a floor.

Race Day + 24 (August 20 - Wednesday)

Everyday for weeks I woke up blood work being done. Then I'd wait anxiously for the doctor to come by, hoping that the levels were finally at a level they deemed it safe enough to discharge me. The visits from family and friends were great, but I was going insane. One of the side effects I'd had was that my vision was really messed up. It took a really long time to adjust to near or far sighted things, so reading or watching TV for a distraction was difficult. With TV I mostly had to listen, everything appeared with double vision. Really felt like the best place for healing and recovery would be at home, where I was comfortable, where people weren't roaming the halls all night or checking in me the moment I finally fell asleep. I don't like wishing time away, but these days often felt endless.

Finally the good news came, the my blood work had improved to the point that the doctors determined it was safe to discharge me. My CK levels were at 1,651 U/L, they debated keeping me, but I was insistent on getting out. The daily routine of whether I'd be discharged has become a significant anxiety causing event, followed by crushing frustration. The paperwork couldn't be done fast enough.

Leaving the hospital may have been one of the greatest feelings in my life. I was thrilled, and overwhelmed with emotion. It is still one of the most vivid memories I have of that time. I do not know if I ever enjoyed a car ride so much in my life, I was like a dog with his head stuck out the window to feel the breeze. Seeing the world up close again, not from a hospital window, knowing I was going home, make me feel like I could recover faster than the doctors believed. "Superman" by Our Lady Peace played on the radio and I do recall breaking down a little.

The doctors told me it would be 2-3 months before I would go back to work. I would be starting outpatient physio services immediately, as I still could not walk without the aid of a walker. My strength had been greatly diminished by the muscle damage in my legs. My medication was down to just blood thinners for treating the blood clots in my legs and I'd need daily outpatient blood work for awhile.

The next day I recall insisting on going to a company BBQ in the park. Jill arranged that they could drive me in fast the gates right to the location. Smelling BBQ food, trees and grass, seeing people (actually, still seeing double of them), and just doing something normal again was amazing. A few days later Jill took me to the mall, basically just to have space to move around. Once I got out of the car, I decided I was not using the walker. With Jill's assistance and liberal sitting breaks, I got through it and never used the walker again.

Race Day + 50 (September 15 - Monday)

After undergoing 3 days a week physio sessions, pool training on my own a couple days a week, and a lot of convincing people I could handle it, I got permission to return to work on a limited capacity. I worked mornings for 5 days a week at in my accounting job. From the day I collapsed to all through my recovery, I cannot thank my employer for going above and beyond to help out/accommodate a contractual employee they had no obligation to.

By this time, my blood work had finally returned to normal levels across the board. I continued to attend physio, but had recovered to the point where I was going the session exercises independently. Speech and fatigue were still an issue.

Race Day + 52 (September 17 - Wednesday)

I ran for the first time since the Tely 10. It was more walk than run. I was escorted by my physiotherapist, and under strict rules, 1 minute running, 2 minutes walking. When my heart rate hit 160, I was to immediately walk again. It was 4.5 km, and it took me 47:30. All that considered it may have been the most gratifying run of my life. And of course I had my Garmin to record it.

Race Day + 71 to 75 (October 6 to 10)

I returned to work full time during this week. I was also discharged from physio therapy. I passed all of their testing without concerns.

Instantly, in my head I was determined to complete a race on Remembrance Day (November 11) about a month from this date. It was an 11K event, and I just wanted to feel the accomplishment of crossing a finish line. It didn’t matter if I could run the whole thing or not, I would walk it, I just wanted to finish a race.

I went back to running with my running group (shout out to New World Running Club) again, but still on restrictions with heart rate and pace. I was getting out very sporadically though. In the end, good judgment prevailed and I sat out the race. I recognized that I was not ready for that exertion.

Race Day + 93 (October 28)

I had a follow-up with the Rheumatologist. He confirmed that the rhabdomyolysis was caused only due to the heat stroke, no underlying conditions, it was a great relief. Strength testing of my muscles revealed negligible weaknesses.

Race Day + 158 to 249 (Fall-Winter)

We had bought a new house in the mid-Fall. January 1, I decided it was time to get back on the road regularly. I was going to take it easy, just run comfortably, not worry about paces or PBs, just get back to enjoying running. I joined the Paradise Running Club (a decision that set me on many running paths), and set out to finalize my recovery.

It started pretty slow. My lungs were fine, but my legs were still building strength. Luckily there were many varying packs of running paces in this group, so I always found someone to keep me going. Through the snowy winter months I kept at it regularly, building up the distances again, and dictating pace by how I felt. I had no thoughts of PBs in my head, just the joy of running with a good group of people.

Race Day + 250 (April 3, 2015 - Friday)

On Good Friday every year, it is a tradition here for runners to run the Tely 10 route, we call it the Tely Teaser. It basically started as a way for the runners who had gone into winter hibernation shake off the rust.

It’s not a formal event, roads are not closed, water stations are not set up (officially), and there are no set start times. But I saw this as a chance to get some mental closure.

I went with a group from PRC, keeping pace with them. Not pushing past a comfortable zone during the run. I hoped I might regain some lost memories as I went by landmarks along the route, but unfortunately I did not. What I did remember, flashed to me vividly though.

The start and finish of the race are permanently marked. The feeling of crossing that finish line was indescribable. I know the conditions weren’t the same, but just making it to end, crossing that line, was a big step towards closure of the recovery process for me. I finished in 92:29 when you count regular rest periods and stops of traffic lights. My moving time (for runners) was 84:57. My heart rate averaged 157 bpm.

The Aftermath (Written July of 2015)

I am now closing in on one year since Race Day. In 2014 about 4,200 people registered for a road race, 3,774 people finished, I was not one of them. I’d never imaged crossing a start line and not crossing the finish line. Luckily most of the near 400+ people who did not finish, had the judgement not to start in the heat, or to withdraw before it was too late.

I came to learn what I had suffered was called exertional heat stroke (EHS). The support I received from friends and family through my recovery, and the feeling of getting back out there, is something that will stay with me forever.

I have completed road races since, I’d love to run the Tely 10 again this year, but due to commitments made prior to last year, I am unable to. Instead I have turned my attention to a local fall marathon. I have been wanting to try a marathon since I started running, but kept putting it off, time to knock it off the bucket list.

I think right now, I could push my pace beyond what I was hitting last year, but I have limited myself to certain exertion levels based on my heart rate. Recently I have been seeing the effects of an improved fitness level. I’m getting more out of my body without pushing to the brink when I’m running. It’s more important to be here for family and friends the next day then hit a PB.

I love running again. I’m not doing it because I feel I need to anymore, I am going out because it is relaxing and enjoying. No more judging a run by how much I’m hurting the next day or two. I’ve done 10+ mile runs since, where the next day, I hop out of bed like I’d done nothing the day before. I’m learning proper training methods.

The primary lingering effect to this day is still some speech difficulties. When I’m fatigued or cold, it’s harder to form certain sounds. All things considered, I know I am very lucky.

I was excited to come across Dr. Casas’ story and learn about the Korey Stringer Institute. It really helped educate me, what is EHS? EHS is a heat illness. Here is an explanation from the Korey Stringer Institute:

"Heat illnesses are a spectrum of illnesses that occur due to heat exposure. This heat exposure can come from either environmental heat (air temperature) or simply intense exercise. These conditions can range from minor heat cramps to life-threatening heat stroke. Contrary to popular belief, heat illnesses do not exist on a continuum. You do not need to have heat cramps or syncope before you have heat exhaustion. As with all emergency conditions, there are steps that you can take to prevent heat illnesses, such as proper hydration, heat acclimatization or body cooling. The key determinant for good prognosis following a heat illness is rapid recognition and treatment. In the case of exertional heat stroke, delay in treatment nearly always leads to long term complications or death. As the preeminent resource on heat illnesses, the Korey Stringer Institute provides the most up-to-date and evidence based information relating to the prevention, recognition and treatment."

I am thankful that my collapsing point was at the fire station, cooling water was immediately applied. I was within close proximity of a hospital, which was another few factor in limiting the damage and increasing survivability.

I think I succumbed to EHS due to two key reasons. 1) Lack of Heat Acclimation. I always avoided running in the heat; waiting for cooler periods. I was not prepared for 70+ minutes of burning sunshine while I ran hard. 2) Fitness level did not match exertion level. As I said earlier, I had mindset to reach my goal, but not the body to get me there. I burned out. The encouraging thing is that I can recognize these issues now (EDIT: Boy was I cocky about that in 2015). I will be prepared for a race, rather than just deciding “I will do this.”

I run with a motto, “It Never Always Gets Worse.” I know now that it’s clearly can get worse; just not always. Sometimes it does. However, even still, in the hospital as bad as things were, it still could have gotten worse.

Other Media

CBC - July 29, 2014

CBC - August 4, 2014

The Telegram - August 4, 2014

The Telegram - July 25, 2015

COMING SOMEDAY - Tely 10 2018: EHS' Revenge