IRONMAN's Medical Director Looks Back at 32 Years of Medical Support
Medical support has come a long way since Dr. Bob Laird's first day on the job.
by Lee Gruenfeld
At the very first IRONMAN in 1978, "Medical Support" consisted of an index card listing the closest emergency rooms. At this year’s event there will be 350 medical volunteers in a well-equipped, 6,000 sq. ft. tent at the pier, including 150 of the best endurance sports physicians on the planet. How that came to be was no accident or inevitable evolutionary crawl. It was the result of a focused, decades-long effort led by one man who saw an unprecedented opportunity to learn while serving, and excelled at both. Meet Robert "Dr. Bob" Laird, Medical Director of the GoPro IRONMAN World Championship and the eighth inductee into the IRONMAN Hall of Fame.
By the way, for you IRONMAN athletes used to getting information from thinly-disguised advertorials, check out some of the things Dr. Bob talks about having learned over the last thirty years. It’s a rare opportunity to hear from someone who uses hard science to back up his conclusions and isn’t trying to sell you anything.
LG: I’d like to take credit for the great opening line (above) about medical support in 1978 but have to admit it was yours.
RL: Thanks, but it wasn’t a line. It’s literally true; I got it directly from John Collins. There weren’t even aid stations back then. Athletes brought their own support groups who followed them around the course.
LG: How much did anybody know about the physiology of extreme endurance sports?
RL: Let me put it this way: We used to weigh people at various points along the course but we didn’t really know why we were doing it or what to do with the data.
LG: Reminds me of those State of Hawai’i questionnaires you get on the plane on the way to Kona.
RL: Turns out those actually make more sense than the IRONMAN weigh stations did, at least at the time. Now, they might actually be pretty useful…if you could get anyone to stop for ‘em.
LG: Let’s step back a little. I detect some Southern drawl…
RL: Born in Atlanta, moved to Tennessee when I was fifteen.
LG: You went to undergrad there?
LG: Were you an athlete back then?
RL: I swam for Vanderbilt, and competed in some NAAU meets over the summers.
LG: Which event?
RL: My freshman coach put me in the 400 individual medley –
LG: Tough event.
RL: Well [clears throat audibly], the truth is he was really just trying to teach me to swim. I took to it pretty good, and worked as a lifeguard over the summers while doing club meets. I eventually focused on the breaststroke but my most memorable finish was third in the 100-yard butterfly at the SEC regional championships.
LG: More memorable than your age-group win in the Hapuna swim?
RL: That was more about fortunate happenstance than anything else.
LG: How do you happenstance your way into a win?
RL: It’s the truth. If I’d been older, younger or female, I wouldn’t have placed.
LG: Sounds more like modesty. So what pointed you towards medical school?
RL: I wrestled with that vs. architecture, and since I was lousy at math…
LG: And why pediatrics?
RL: It was that or be a veterinarian, and vet school was too hard to get into.
RL: Really. But there’s not that much difference between the two.
LG: Excuse me?
RL: The patients can’t tell you what hurts, they sometimes bite…
LG: You do know that this is going out on the Internet, right?
LG: Never mind. How did you get from Tennessee to Hawai’i?
RL: After my internship and first-year residency I wanted different academic and geographic exposure, so I applied for positions all over the west. I got an immediate acceptance to be chief resident in pediatrics at Children's Hospital in Honolulu, so I moved there in 1971, stayed a couple of years and then went back to a little town outside of Nashville.
LG: Didn’t like Hawai’i?
RL: I loved Hawai’i, but I had an opportunity to join a great private practice and also to become an assistant clinical professor at Vanderbilt.
LG: But eventually you came back.
RL: In 1977 I attended a medical conference at the Mauna Kea. I looked up some old friends, and they told me that there had never been a full-time pediatrician in Kona, and there was a medical group looking for one. I was offered the job and moved here in 1978.
LG: Coincidentally, the year of the first IRONMAN.
RL: I had no idea what that was until 1981, when it moved to Kailua-Kona. Valerie Silk, the owner, met with some locals, including a friend of mine named Curtis Tyler, a swimmer who later became a local politician. They said they needed a physician at the swim, and would I be willing. I had no idea what to expect – nobody did, really – so I showed up down at the pier with a stethoscope.
LG: Was it challenging?
RL: Standing around with nothing to do was very challenging. But then I came back for the last half of the race and got all the complacency knocked out of me in a hurry. It was so nuts that the other local doc who was also a medical coordinator didn’t come back the following year.
LG: Is that when you inherited the entire job?
RL: Yes. I got a few local physicians and nurses to pitch in, and we put some procedures in place along with a few logistical improvements. But we were still pretty much dancing in the dark, trying to apply conventional medical practices to a situation that was anything but conventional.
LG: I’ve heard that 1984 was a watershed year for you.
RL: Not just me, but medical care for the race as well. That experience almost did me in completely.
LG: How so?
RL: By then we had a 30 x 30 tent, and, as we discovered, "If you build a tent, they will come." We had more medical volunteers, more cots, added lanais to hold even more, there were two or three athletes seizing in the medical tent at the same time.…we got overwhelmed. Our supplies came from the hospital, but with little previous experience and a rapidly growing number of participants each year, we could only guess at how much to stage in advance. So we had people running back and forth to get more, and we ran out anyway.
LG: You mean IV fluids?
RL: Yes. In the very early days it was considered wimpy to get an IV, like somehow you weren’t tough enough to handle IRONMAN conditions. But when people started to realize that it aids recovery, everybody wanted one. In 1992 we administered over 550 liters, and that was when we had only 1,364 starters.
LG: That’s a lot more than I would have guessed.
RL: That was the peak. It’s dropped drastically since then. Last year  we only gave 226 liters, and there were over 1,800 starters.
LG: How come?
RL: Athletes have gotten a lot smarter about how to stay hydrated, and we doctors got more selective about who really needs to get fluids intravenously. In the beginning we gave them out like candy because we didn’t know any better and were afraid not to. We felt everyone was dehydrated to some degree and knew most would recover faster.
LG: I’d have thought there would have been a lot of precedent by then. All those marathons everywhere in the world…
RL: There’s endurance, and then there’s IRONMAN. We knew that, once you start creeping up into the four- to six-hour range, where middle- and back-of-the-pack marathoners are, the rules when it comes to human physiology start to change significantly. But when you get into the eight- to 17-hour territory of IRONMAN, you throw the entire book away.
LG: Reminds of when we went from subsonic to supersonic flight. At first nobody was even sure it was possible—
RL: —and when they found out it was, they also discovered that the traditional notions of what worked and what didn’t weren’t going to cut it anymore.
LG: So what got you thinking about it as more than a passing curiosity?
RL: That 1984 race along with a little serendipity. A neurosurgeon in Michigan, who’d helped develop the modern football helmet, was putting together a sports medicine textbook and wanted to include a chapter about triathlon. The task eventually fell to me, which was fine because the quickest way for me to expand my knowledge about something is to be faced with having to write an article about it.
LG: I know the feeling well. Except I’m a fiction writer and can just make it all up.
RL: That doesn’t work well when you’re a physician.
LG: My doctor thinks it does. Anyway, how’d you go about it?
RL: The way all good projects should: With a bunch of people who had the right skills and plenty of enthusiasm. Doug Hiller, an orthopedic surgeon and IRONMAN athlete, got together with some colleagues and started an outfit called Labman to do research at races all over the country. IRONMAN also had a large contingent of Japanese athletes and Hisao Iwane, a cardiologist from Tokyo, was doing research on them. We in Kona had been keeping basic statistical records on our experience with IRONMAN: condition reports, liters of fluid administered, feedback from questionnaires. Most of that was for race purposes, but it turned out to be invaluable when we got serious about the medical research side.
LG: Why collect the stats in the first place?
RL: We wanted to be as scientific as possible in providing care. Studying the records quantitatively helped us predict what would be needed under varying conditions.
LG: Sounds easy: The hotter it is, the more IV fluids you’re going to need.
RL: You’d think so, wouldn’t you? As it turns out, the most important factor affecting the need for medical attention at the world championship is wind.
RL: We generally know within a few degrees either way what the temperature is going to be on the Kona Coast every day for the next twenty years.
LG: The same as the last twenty years?
RL: Exactly. Few surprises there.
RL: [continues] But whether the winds are going to blow at five knots or thirty is anybody’s guess, and if it’s thirty, athletes are going to be out there working harder, for a much longer period of time and the medical tent is going to get inundated.
LG: I just remembered: You’ve done IRONMAN yourself, right?
RL: Twice. The first time in 1988, and then again in 2003.
LG: Did doing the race help you to "get it," from the athlete’s point of view?
RL: Big time. I never looked at the race the same way again, but it was about more than just the athletic experience. There were two things that left a deep impression. One was the beauty of the course, which had never really struck me that hard as a spectator.
LG: And the other?
RL: The spirit of the volunteers. You hear about it all the time but to be on the receiving end of all that enthusiasm and energy was truly mind-blowing.
LG: How’d you do?
RL: Pretty good, I think. In the first one I finished in a respectable 12:41.
LG: That’s a lot more than respectable. How about the second time?
RL: Well, the first time was a solo effort. The second time I did it with my best friend and my son, and it was a very different but much more emotional experience. I was also 15 years older.
LG: I have to ask: Did you get IVs afterward?
RL: Both times! And both of those years were relatively wind-free.
LG: Which one was harder?
RL: My toughest IRONMAN was in 2000.
LG: Hold it: You didn’t do it in 2000.
RL: No, but my wife Mary did, and watching and worrying were much harder than doing the race myself.
LG: How long have you been married?
RL: Since 1990. Mary was my office manager and medical assistant.
LG: I heard you two have done some serious mountain climbing.
RL: We’ve been trekking in Nepal, and I climbed a 21,500’ peak once.
LG: That’s impressive. I could hardly take ten steps up on Mauna Kea without wheezing my lungs out, and that’s 7,000 feet lower.
RL: Those days are gone for me but we sure loved it.
LG: Getting back to the research. So you had some basic data gathered…
RL: And we’ve continued to gather it, right up to the present day. Another thing that happened was that Ross Labs, an infant formula manufacturer, had been thinking about coming out with a sports drink. I got them together with IRONMAN, and the drink they eventually came out with was Exceed. They sponsored IRONMAN and took me on as a spokesman, so I went to various races, competed in them, and gave talks on hydration and nutrition. I got a lot of exposure to different theories about endurance sports, and then made it my goal to pull together medical directors from events covering the three individual legs of triathlon to see if we could combine all that knowledge and come up with a unified approach. Ross organized a symposium in New Orleans and, as co-chair, I got to pick the participants and edit the symposium report.
LG: What kinds of people did you get?
RL: The best and most experienced medical directors around, including those from the Boston Marathon, the Coors Classic Bike race, the Western States 100, IRONMAN Canada, the New York Marathon…
LG: Impressive crew.
RL: They were very eager to share information and to take what they heard back to their own events. This was about the time we were starting to recognize hyponatremia as a discrete condition, and to distinguish different causes.
LG: Low salt. I thought that’s what happened when you perspired a lot.
RL: That’s only one type, and we discovered that excessive sweating doesn’t necessarily cause it. People who are properly acclimated to conditions in Kona don’t lose as much salt through sweating as those who aren’t used to some heat and humidity.
LG: That’s something I’ve always wondered about. I live in the desert and play a lot of golf. The first round or two when summer comes are always difficult, but after that I play all summer long in temperatures as high as 118 without problems. What’s the mechanism involved in acclimatization?
RL: I wish there was a simple answer, but in fact it’s very complicated and involves a lot of interlocking factors. The foundation is something called homeostasis, which is the tendency of the body to maintain stability among all its system: blood pressure, heart rate, respiration, hormone levels, blood oxygen levels…any time something attempts to upset that equilibrium, there’s a reaction to try to restore it.
LG: So if you’ve been sitting still and suddenly get up and start running…
RL: There’s a whole cascade of reactions. Your muscles start drawing more oxygen from your blood, so your respiration rate increases to get more oxygen into the blood. At the same time, the heart pumps faster to get that oxygen to the muscles, which themselves are altering chemical levels in order to supply more power.
LG: How does that relate to acclimatization?
RL: When you find yourself in hot weather, you start to perspire more, as part of the body’s attempt to keep its temperature constant. It’s a pretty effective evaporative cooler, but it reduces your hydration level and also pulls salt out of your body. It takes a few days for the system to figure out how to cope.
LG: What does it do?
RL: A bunch of things. For heat, specifically, you start to sweat earlier but there’s less salt in your perspiration. But, again, there’s a large genetic component. So it’s not unusual to see two people come across the finish line together, having been out on the course for the same amount of time, but one of them looks like he’s been dipped in flour and the other doesn’t have a salt spot anywhere on her.
LG: How do we know that this is because of genetics?
RL: It isn’t always, but it might be. Here’s a concrete example: People with cystic fibrosis put out a lot of salt in their sweat. The CF gene is recessive, which means that people can carry it without manifesting the disease, but many of them will still have inherited that tendency toward very salty perspiration. The important point is that, while we can make large, sweeping statements about what’s likely to occur, on an individual basis it’s vey hard to predict. The good news is that the kinds of things you would do to mitigate those problems, like staying well hydrated and consuming electrolytes, have virtually no downside.
LG: Back up a second. If you don’t sweat out the sodium, does that mean you’re not at risk for hyponatremia?
RL: You’d think so, wouldn’t you?
RL: Well, you’d be wrong.
LG: Had a feeling you were going to say that. But how can you get low on salt if it’s not being lost with perspiration? Wait: You said there were two types of hyponatremia.
RL: A perfect segue, and this brings us to a physician from South Africa named Tim Noakes. In the late 90s he worked with an event down there called the Comrades Marathon.
LG: I’ve seen it up close and personal. A hilly, fifty-six mile run.
RL: A brutal race, but people come from all over the world to run it. When really fit athletes were seen walking portions of the course, everyone assumed that they’d become dehydrated even though they swore they’d been drinking bathtubs full of water. Tim thought about how that could be, and suspected that all of that plain water might have been diluting electrolytes and therefore actually doing more harm than good. Electrolyte disturbances are closely correlated with distance as well as heat. Water’s just fine if you’re not going to be running more than about four hours, but after that, you can get into trouble quickly if you don’t mix in some electrolytes. We see it happen to people here out on the bike course, even before they get to T2 and start running.
LG: And that kind is called…
RL: Dilutional hyponatremia. As opposed to losing sodium from the body, it’s still in there but may be insufficiently concentrated to be fully useful.
LG: Does that have anything to do with why so many IRONMAN competitors have lower G.I. problems out on the course? Cramps, vomiting, the trots…I always thought it was all that pounding and exertion interfering with the digestive process.
RL: Exertion, yes, but not the pounding, because it can happen on the bike, too. There’s actually a fascinating explanation, and it has to do with blood distribution and oxygen, not sodium.
LG: I’m stumped. Let’s hear it.
RL: The blood delivers oxygen and fuel throughout the body, and also whisks away "metabolic trash." As long as you’re not working too hard, there’s plenty of blood to service all of your organs. But when you start cranking up physical activities to the point where organs are competing for available oxygen, the brain starts making trade-offs.
LG: I bet that the brain, being in charge, gets top priority.
RL: It does. The brain’s #1 job is to protect itself and it’s perfectly happy to let everything else shut down in the attempt. But before things get that far, it’s pretty selective, and it has to do with what’s most important right now. Well, digestion is one of the things that can wait, so the gut is the first to have its blood supply compromised when the demand starts to rise.
LG: What happens when the blood supply drops?
RL: One of the more noticeable effects is that you lose the ability to absorb fluids from your stomach. Pile that on top of altered stomach-wall permeability during extreme exercise and it not only contributes to dehydration and low salt levels, it also adds the complication of a lot of liquid sloshing around in your belly. It has to go somewhere, so…
LG: It’s either up or down.
RL: Or both. Vomiting, diarrhea, and also cramps because you’re not digesting properly.
LG: Sounds almost like cholera.
RL: The cause is different – cholera comes from a bacterial infection – but the effects are similar. One key difference is that the loss of blood to the athlete’s gut, a condition known as ischemia, can result in cell death if it’s extreme and goes untreated. And, as you know, dedicated athletes tend to "run through the pain." Normally, that’s not harmful in the long term, but with intestinal ischemia, it’s downright dangerous. Several pro athletes have had parts of their intestines surgically removed because of it.
LG: Lewis Carroll said that only the insane equate pain with success.
RL: Yes, but in the same book Alice tells the Mad Hatter, "You're entirely bonkers. But I'll tell you a secret. All the best people are."
LG: Touché. I took you off track there. We were talking about dilutional hyponatremia.
RL: Yes. So one of the things that tends to happen when researchers discover something new is that a lot of people jump on the bandwagon and think, "This is it!" rather than "This may be part of it," before the hard work of nailing it down is done.
LG: Hence, all of that very public flip-flopping on what’s good for you and what’s bad.
RL: Exactly. So Tim decided that over-hydration was the basic problem in endurance racing. He wanted to limit giving out plain water, move aid stations farther apart, withhold IVs in the med tent, things like that, and they seemed to work fairly well at the Comrades Marathon.
LG: What about for the IRONMAN in Kona?
RL: Well, Tim is a good guy, very smart, very serious, so when he came to Kona about fifteen years ago, I put him in charge of one section in the med tent, where he was going to try things out his way. Who knows? Maybe we were going to see a revolution in the medical care of endurance athletes. Athletes in that section were pretty much treated as they would have been had they been sent to what we call the "weak and dizzy" area: lay them down, get their feet up, sip a little bit of fluid, no IVs.
LG: Let me guess…
RL: The section was closely supervised by experienced charge docs, and it became real clear, real fast, that things weren’t working. Like I said, Tim was a good guy and a good doc. It’s just that things aren’t ever simple. Yes, IRONMAN in Kona is a very different event, under very different conditions, than the Comrades run in South Africa, but it’s more than just that. There’s no single cause for hyponatremia, and therefore no one-size-fits-all treatment, and hyponatremia is never the only problem. And I’ll throw something else in the mix just to show you how complicated things can get: The amount you sweat is not only a function of your exertion level and the outside temperature and humidity, but of your hydration level. The body wants to stay cool, but on the homeostatic priority list it pales next to the need to stay hydrated. So if too much water is being lost, you stop sweating. With that cooling mechanism out of service, your temperature rises, more blood is sent to the extremities in an attempt to radiate heat through the skin, less blood is available for muscles, for digestion…
LG: So if you’re working hard in hot conditions and stop sweating…?
RL: You’re in real trouble. The unavoidable truth is that dehydration is far more common than "simple" dilutional hyponatremia, so withholding fluids as a standard treatment is just not smart.
LG: One thing we haven’t talked about is plain old exhaustion. When we see people collapse at the finish line, the conventional thinking is that they have absolutely nothing left in the tank and hit "Empty" with the last footfall. I always thought that there was actually a lot left, and that the "I couldn’t take another step" feeling was at least partly psychological because nobody could time it that close.
RL: Physiologically, there’s probably plenty left. If a lion jumped down from the banyan tree on Ali’i and started chasing that "completely spent" finisher, you’d better believe he’d take off again. But there’s also a physiological explanation for the finish-line collapse.
LG: And that is…?
RL: The athlete collapses because he stopped running.
LG: Legs are too weak and shaky to start up again?
RL: Much more interesting than that. Remember how the body apportions oxygenated blood according to need?
RL: It does the same when it comes to moving that blood around. There’s a phenomenon called the "second heart" that occurs when you’ve been running continuously for a long time. The large muscles of the legs assist in pumping blood up from the lower part of the body when you run. After a while, the brain figures out that the heart is getting some help, and it starts to depend on that assistance. The longer you run, the more the brain trusts that mechanism and turns its attention elsewhere. Then when you hit the finish line…
LG: No more help from the legs.
RL: Resulting in a sudden drop in blood pressure and less oxygen going to the brain. So you feel faint, maybe dizzy, not because you’re exhausted but because you stopped running and therefore stopped helping blood to go back up. Plus, if it’s hot, a lot of blood has already been diverted to the skin in an attempt to cool it down. To make things worse, your legs turn to jelly because they’re getting less blood now, too. Add a bit of dehydration and you’ve got a perfect "Oh, just shoot me now" storm.
LG: Interesting. Is that why you’re supposed to lay someone down and elevate their feet?
RL: Exactly. The easiest way to get blood flowing back up from the legs is to let gravity do it, and keeping the head low with respect to the rest of the body gets oxygen back into the brain quicker.
LG: What about those people who come across the line feeling just fine and then collapse in their hotel rooms an hour later? Happened to a friend of ours after IRONMAN China.
RL: It’s pretty common. When your ability to absorb fluids is compromised because of intestinal ischemia, the simple cure is to stop exercising. That restores blood flow to the gut and allows you to start absorbing fluids again. The problem is that your stomach is full of all that accumulated fluid and your cells are crying out for it, so the shift may be very abrupt. When that happens, you can get temporary imbalances in electrolyte levels, insulin, glucose, etc., which manifests in fainting, nausea, chilling, or all of them. If it's really severe, you can become acutely hyponatremic and go into convulsions. Thankfully, that’s very rare, but it’s one of the reasons we don’t shoo people out of the med tent the minute they feel better. We like to see some stability first.
LG: That really is fascinating stuff. Let’s talk about how that knowledge was earned. Earlier, we were talking about the gathering of medical directors back in 1987. Is that how the annual IRONMAN Sports Medicine Symposium began?
RL: No. There has actually been a medical meeting prior to the IRONMAN World Championship every year since the early 80s, and it’s become one of the most prestigious in the world.
LG: Do any of the attendees stick around for the race?
RL: Nearly all of them do. Working the race is one of the highlights of the meeting, because participants can immediately put their learning to use in the real world. The single thing I’m proudest of after all these years is that the medical tent is as much a teaching facility as it is a treatment center.
LG: Let’s talk about that tent for a second. How is it set up? Do you have newbies working alongside veterans?
RL: Yes. The tent is divided into sections of six cots each, with a doctor, an assistant and a runner who can fetch supplies. Each group of three sections is under the supervision of a charge doctor, a veteran experienced in IRONMAN medicine and our procedures. We’ve got seven or eight of those present at a time, as demand dictates. One of our guiding principles is that no medical volunteer ever steps out of his comfort zone. We have immediate consults if an athlete starts to go bad, and standards for how much IV fluid can be given without additional approval, whether special meds can be administered, under what conditions should people be sent to the hospital…
RL: How big is the staff?
RL: About 350, although not all on duty at the same time. Roughly 150 of those are doctors.
LG: Are there specialty areas, or are the sections all "generic?"
RL: The sections are generic – we want to distribute the athletes so all the medical volunteers get some experience – but we also have a triage area, where greeters weigh athletes and can send them to the "weak and dizzy" area to see if they can recover without IVs. There’s also a kind of mini-ICU, where we bring athletes who collapsed before the end of the race, which is usually much more dire.
LG: Is that because it has to be something major before a competitor will end his race after training for a year?
RL: Pretty much, like some kind of trauma, or a previously undisclosed or unknown existing condition.
LG: One last question: Given what you’ve seen, what kind of advice would you give prospective Ironman athletes to lessen the likelihood of them visiting you on the pier?
RL: The first and most basic is, stick with whatever hydration and nutrition plan has been working for you during training.
LG: Come on, that’s old hat. Give us the benefit of thirty years of research.
RL: Well, that was race-week advice, and isn’t it a race-week blog you’re writing?
LG: Fair point. But since people save my articles and read them over and over for years [Dr. Bob is rolling his eyes; must be some kind of condition], what would you tell someone preparing for an Ironman in 2014?
RL: I’d suggest keeping your hydration and nutrition plan as simple as possible. There’s really no need to eat during an Ironman, and it’s a lot easier to absorb sugar, salt and water than proteins and other hard-to-digest stuff.
LG: Age group champion and course record holder Sue Osborne used to put cheeseburgers in her special needs bag.
RL: And the 1932 Tour de France winner smoked three packs a day during the race, so what’s your point? Anyway, aside from being easier on the body, the simple stuff is also a lot easier to remember, less complicated, less troublesome psychologically. This is especially important for older athletes and those who will be out on the course longer and might get addled by the conditions. When you’re hurting, and it’s all you can do to just keep putting one foot in front of the other, who wants to be making decisions about what to eat and drink, especially when there’s no proven benefit to that added complexity?
LG: Keep It Simple, Stupid?
RL: I wouldn’t have put it quite that way, but…yeah.
LG: How come you’re looking at me when you say that?
RL: I don’t know. Must be a condition.