Eliud Magut is a Kenyan athlete with a marathon best of 2:10. He’s now perhaps more famous because of the video posted below, showing his dramatic final kilometers in the Padova Marathon this past weekend.
The video has sparked a storm of discussion and criticism of the race organization and the guy on the bicycle (apparently his agent) whose voice you will hear throughout encouraging him to “finish”. Magut fights on for a while, falling to the ground on a few occasions before picking himself up, then using the fence barriers to stagger towards the line. Ultimately he fails, collapsing for the final time (around 2:52 into the video) before he is carried away on a stretcher, into an ambulance, and off to hospital.
First, the good news – he recovered rapidly, and was discharged with no apparent ill-effects. A statement from the race said that he had “a hypoglycemic crisis (low blood sugar) and dehydration”, but that he was in a “newfound best condition” by the afternoon. The statement also defended the race management of what many accused was a life-threatening situation, alleging that the race neglected to provide proper care to a stricken athlete.
For example, one journalist posted the following on his Facebook wall:
“Magut would have died as the medics watched, urging him on like a prize horse! Athletics Kenya really must act on this sort of modern slavery, in my opinion. Absolutely disgusting! The health of the athlete must come first”
I want to discuss some of the responses, and also the physiology of those final kilometers, because they are a dramatic illustration of what may be going on at the very limit of fatigue and performance. That in turn has implications for how the athlete would be managed.
[ribbon toplink=true]Ethical obligations vs athlete incentives[/ribbon]
Dramatic finishes such as Magut’s during endurance events are not exactly rare. Some of the most inspiring moments in endurance sport happen when athletes reach a limit and then fight their way to the finish line. It’s rarely pleasant, and when you show clips like this to a mixed audience, they’re usually met with a combination of horror and admiration or honor. Those who admire it, you’d be safe to bet, are those who are endurance athletes themselves.
Offhand, I can think of a few famous examples – Sian Welch and Wendy Ingram at the Ironman 1997, Jim Peters in the 1954 Vancouver Games Marathon, Julie Moss in the 1982 Ironman Triathlon, Kayoko Fukushi of Japan in 2008, and Gabriela Andersen-Schiess in the 1984 LA Olympic Games marathon.
The physiology behind those collapses differs – Peters and Andersen-Schiess are supposed to have been heat-related, while the others, like Magut’s in Padova, are hypoglycemic in nature (but more on this later).
The point is, highly motivated athletes can, and do, drive themselves to the point where dramatic failures in normal homeostasis are possible. The problem is that for every Peters, Moss, or Welch, which produced impressive highlights that motivate a select few hardy endurance souls, there are similar cases which result in death during exercise, and so the fear is real because history has shown it to be.
Now, the debate with Magut is whether the medical support of the race should have intervened right at the start of his problems. You will see in the video a man wearing yellow walking alongside Magut for the duration of the clip. That man, I believe, is a medical volunteer who was dispatched to support Magut when he started to struggle and show signs of mental dysfunction. According to the statement issued by the race, this man repeatedly encouraged Magut to stop.
The other man on the course, riding the bike, is apparently the athlete’s agent and he is encouraging him to finish. We don’t know whether Magut had any response to these conflicting messages. He doesn’t seem capable of responding in the clip, but it’s feasible that he has said something, perhaps that he wants to continue. He was lying in third at the time, a prize-money position, and that’s a powerful incentive.
I don’t see Magut being co-erced or unreasonably driven by others in the clip. The agent has an incentive to force the runner to finish, of course, but the runner’s incentive is greater. If you or I would give everything to finish, to the point of running ourselves to collapse, then how much more for a motivated elite athlete, presumably paid to race and paid to win? And remember, the outcome of this race has implications for future races, so it’s not merely 600 Euros for third place at stake.
So, if the athlete is not forced to continue, then is it fair to equate him with a “prize race horse” and the race with “modern slavery”? I believe both are unnecessarily extreme comparisons.
[ribbon toplink=true]Medical requirement to intervene[/ribbon]
But wait. It’s not that easy, either. Just because he is not forced to run doesn’t mean there is no fault. The problem, medically, is that there is a requirement for reasonable care, and there will come a point at which it becomes unethical NOT to intervene. The athlete may not be forced to run, but medically, it may be that they should have been forced not to!
If any of you have ever exercised yourself into serious hypoglycemia, when your blood sugar plummets and you lose the ability to think clearly, become confused and disoriented, then you’ll appreciate that maybe in that state, you are not exactly the best judge of what you should be doing.
So too, for Magut, his clearly compromised mental state would warrant some kind of intervention, if only because it is a symptom of a number of possible conditions, some of which are actually relatively easy to treat, with no major long-term consequences, whereas others are very serious medical conditions, requiring immediate intervention. Delaying the diagnosis, and thus the treatment, is the basis for criticism, which says that it’s not enough simply to suggest that the athlete stop, but rather that medical support should force him to.
[ribbon toplink=true]The physiology of collapse[/ribbon]
At the risk of deviating from the practical discussion for a moment, it’s important to understand the physiology of what you’re looking at in the clip. If a runner is in a potentially serious medical situation, then the minimum medical requirement is a diagnosis and the appropriate treatment. As it turns out, Magut was hypoglycemic (I’m assuming the statement was accurate, and also his symptoms and apparent speedy recovery support it). This is, as far as the possibilities go, not too bad, and recovery is rapid once treated.
But hypoglycemia is one possibility. Another is hyperthermia, which comes in various stages of severity, but with much research showing that at the critical limit of around 40 C, mental function is affected and confusion and loss of co-ordination can occur (all of which were evident in the clip). Beyond this, as temperatures reach 41 or 42C, loss of consciousness and permanent damage occur. Also note that hyperthermia is not limited to hot days only, and many cases have been documented where relatively slow runners, in cool conditions, have developed fatal heat strokes.
The situation is complex, however, because the physiology of athletes at the limit is complex and thus messy. Take for instance the famous collapse of Jim Peters in 1954. At the time, Peters was the world’s best marathon runner, and he entered the stadium in Vancouver 17 minutes ahead of the second place runner, but in serious trouble. He staggered around for a few minutes, collapsing on the track, before eventually being carried off to hospital as a DNF. His collapse has always been though to be a simple case of heat-stroke – he ran fast enough to produce heat that he could not lose on a hot day, and the result was that he overheated.
It’s a little more tricky than that. As was reported in a paper a few years ago, Peters’ body temperature an hour after this was “only” 39.4C, which while hot, is not in the territory that constitutes heat stroke. Instead, it was theorized that his collapse was due to “a combination of hyperthermia-induced fatigue which caused him to stop running; exercise-associated postural hypotension as a result of a low peripheral vascular resistance immediately he stopped running; and combined cerebral effects of hyperthermia, hypertonic hypernatraemia associated with dehydration, and perhaps undiagnosed hypoglycaemia. But none of these conditions should cause prolonged unconsciousness, raising the possibility that Peters might have suffered from a transient encephalopathy, the exact nature of which is not understood” (Noakes et al, 2008).
His body temperature was admittedly measured an hour after collapse, and it’s possible that he’d reached 41C before cooling down, so I wouldn’t totally discard the heat theory. My point is that the physiology is complex, with potentially many ‘system failures’ interacting with one another. When you watch those clips of Sian Welch and Wendy Ingram, for instance, you’re probably looking at muscle cramp, muscle weakness, central nervous dysfunction perhaps due to hypoglycemia, hypotension or low blood pressure perhaps due to cardiac pump insufficiency or cerebral blood flow deficiencies, and maybe hypernatremia. Add the possibility of hyponatremia, and the collapsed athlete is a very complicated matter indeed.
[ribbon toplink=true]Collapsed athletes, Foster positions and pathologies[/ribbon]
Recently, a paper on the implications of collapse for our understanding of pacing and fatigue offered the following theory, introducing the “Foster collapse positions” (all of which are demonstrated by Magut):
The Foster collapse positions are indicative of a final, likely primordial, protective mechanism designed to attenuate postural hypotension, cardiac ‘pump’ insufficiency or cerebral blood flow deficiency. Continuing to attempt to reach the finish line in this impaired state is also perhaps indicative of a high psychological drive or a variety of neurological and psychological pathologies such as diminished sensitivity to interoceptive feedback, unrealistic situational appraisal or extreme motivational drives (St Clair Gibson et al 2013)
By that definition (which I believe to be accurate for normal situations, but not pathologies), a collapsed athlete can actually be the manifestation of the final stages of homeostasis. It’s much like soldiers who faint while on parade, or tennis ball-boys who drop during long rallies. They’ve experienced a short term ‘failure’ of BP regulation, which is rapidly corrected by the somewhat dramatic fainting response. No big deal, ten minutes later.
The same is true when athletes collapse AFTER crossing the finish line. What happens then is that the blood that was previously circulating thanks to the contraction of muscles suddenly ‘pools’ in the legs because of peripheral vasodilation (the blood vessels in the legs have dilated to allow more blood flow to the muscle).
The blood pressure drops and the athlete collapses. Many runners end up in the medical tent for this reason, but they’re quickly treated by elevating their legs, and are discharged with no ill-effects.
What the medical officials in the tent are more worried about are athletes who collapse and lose consciousness DURING running, out on the course. They are often much more severe, potentially cardiac, heat or hyponatremia-related, and nowhere near as ‘innocuous’ as post-race collapses.
The point is, athletes collapse for a number of reasons, and sometimes, collapsing is not necessarily a crisis, but the physiological ‘plan B’ to avoid the crisis. However, in other instances, it’s the result of a very serious failure, a pathology and a medical emergency.
And while telling them apart is not pure guesswork (the timing of collapse – before vs after; and associated symptoms and context including chest pain, breathing, body temperature & environment conditions all inform a reasonably good impression of the cause), you absolutely have to tell them apart in order to treat them appropriately, or allow the athlete to continue for a short time with some intervention.
[ribbon toplink=true]Relax the Assistance = DQ rule[/ribbon]
And that is why Magut needed, at the very least, to be stopped in order to ascertain some indication of the problem. The rule in these races that any support offered to an athlete causes disqualification is therefore part of the problem. Athletes are highly motivated, and we want that. We also want to encourage them to perform to the very limits of their ability, which by definition means they’ll frequently push up against these physiological “crises”.
What should be allowed is for the athlete to receive some support very early on – the collapse you saw in the clip comes at the end, and can be predicted many minutes in advance. When that happens, the athlete should be able to speak to a medical official, possibly receive some assistance that does not actively move them to the finish line (Magut might have needed a five minute break before walking to an energy table for some sugar or the final kilometer to the line without the threat of DQ), and a more informed decision to be made.
Remember last year on Alp d’Huez when Chris Froome realized that he’d be in trouble because his blood glucose levels were falling? He made it to the top, albeit slower than he might have liked, after taking on an admittedly illegally-timed energy drink. That tells you that if you catch a developing problem early, the solution need not be all or nothing, and dramatic collapses might be avoidable with some kind of early intervention. It may require a financial penalty (as in Froome’s case), but I’d suggest that’s better than the alternative.
What we have now is people guessing, watching in horror, and a highly motivated athlete (not a prize horse or a slave) pushing through an unknown problem to cause nothing but controversy. Once an athlete collapses, medical care should be immediate. The risk of death is probably small, and most of the reasons causing collapse are easily treatable, but why take that chance?
PS. In response to the post, there was some good discussion on our Facebook page, where some of you raised interesting questions about “free will”, ethical care, and the non-event of this collapse. I tried to respond to comments there, and it is an interesting read/debate to continue on from this piece.