Running the Sahara, Part 6

by Jeffrey S. Peterson, MD

As our entourage approached Cairo, it was decided that the running would be timed to enter the sprawling, polluted, and congested city at dawn. Thanks to police and army escorts, the run passed through the city without dangerous incident, despite dense auto and pedestrian traffic. In the city, we paused only a couple of times for brief rest, nutrition, and medical care (including once on a bridge spanning the Nile River, an experience that can only be described as surreal).

From there, we began the run’s last 36 hour leg down a four-lane toll road leading to the Red Sea. The runners had decided to run non-stop to the finish for the last 48 hours. Despite our hope that evenings and nights would be calm due to reduced traffic, we were sadly mistaken, and spent the night barely sharing the road with non-stop, speeding 18-wheel truck traffic; the roaring and booming passage of which not only buffeted everyone in its wash, but which also proved unnerving to the runners so close-by and unprotected.

By this point, all of the runners were on minimal doses of oral narcotics to deal with their pain and prednisone to lessen the severe tendonitis and general swelling that had become debilitating in each of them. This is not surprising, given the fact that they had run more than 4,000 miles in 110 days.

Overnight and into the next dawn, all three runners had nearly ceased communicating with one another, talking instead to family, friends, and supporters. One began to hallucinate and was frequently disoriented. Several times during the night, he lay down in the middle of the toll road in search of rest. After appropriate caffeine, hydration, and emotional support, he would continue on.

Athough the runners were within 25 to 30 feet of one another, they were in their own worlds; at times, they were disoriented and psychologically isolated. Miraculously, despite the near-misses, dangers, and craziness of the night, dawn arrived without a major incident. With daylight, the trucks left the toll road. As our escorts didn’t want to pay the tolls, they also departed, leaving our group alone on a virtually unused road. It had become abundantly clear, however, that two of the runners required some sleep if they were to finish the remaining 50 kilometers.

One of these men, however, was very concerned that were he to stop running and rest, he would be incapable of re-starting and once again gaining momentum. Consequently, he wanted to continue walking—making minimal progress—as he waited for the others to catch up.

It was decided by all three runners that two men would stop on the side of the road and rest for one to two hours, while the other proceeded on. This was calculated to be acceptable, given the extremely low pace being kept by the sole runner, who sported a painful abscess on his left foot. In all the stopping and starting, his determination to regain momentum was the only thing propelling him forward.

Prior to this period, it was clear that the road warrier's once angry-looking blister had turned into a very frank abscess draining purulent fluid. Severe pain associated with the affliction led to significant alteration in gait and stride, initiating an entirely new series of over-use injuries.

Perhaps it was attributable to disorientation, a desire to end the pain, end the run, or innate hyper-competitiveness, but before long our man began to pick up his pace. Soon, he was covering 15 kilometers an hour or more. After a quick calculation, I radioed a relay signal to the remaining (resting) runners through a unit of the film crew trailing us. They had overslept.

My apprehension and fear were replaced by jubilation when I looked in the rearview mirror and saw two small figures rapidly approaching from behind. We estimated that, in order to catch up, they covered 18 to 20 kilometers an hour. They rejoined their companion eight kilometers from the Red Sea. Upon reaching him, with wide grins on their faces, they said in unison, “Are you headed to the Red Sea?”

At this point, the runners were nearly totally spent, and covered the next few kilometers with a gradually slowing pace, spurred on by the watery finish line in sight. With merged support teams—African, Taiwanese, Canadian, and American—cheering them on, everyone stepped from their vehicles to walk the last three kilometers with the runners in support of finishing this epic run and journey. At the Red Sea, each runner dipped his hands, and after 111 days of every roadblock, logistical nightmare, and impediment imaginable, the expedition had succeeded. The physical achievement and psychological stamina were unrivaled in my eyes.

On February 20, 2007, just a few hours before sunset, it was complete. The remarkable runners had covered 6,920 kilometers (4,300 miles). Aside from the accomplishment of finishing, the expedition saved the lives of two, changed the lives of many, and in the future will hopefully improve the lives of countless, through its mission of supporting integrated sustainable water programs in Africa.

photo above by Jeff Peterson

Thanks, Jeff, for this fantastic series. You are a phenomenal storyteller, and we look forward to learning about your next adventure.

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Running the Sahara, Part 5

by Jeffrey S. Peterson, MD

Contrary to what one would think, because of our government and military-security escorts in Libya, we were likely the safest we had been in all six “Running the Sahara” countries. Amazingly, the runners continued to pound out consecutive, 50-mile days.

Like the Niger Army solders, however, our new escorts also needed medical assistance, although at first—before I could provide treatment—they would ask me to show them the protocol in my Field Guide to Wilderness Medicine, by Paul Auerbach, MD. Eventually, trust was gained, and once again I was providing sutures, antibiotics, diabetes treatment, joint wraps, and—as always—treatment for eczema and more plantar warts, the latter which seemed to be a regional epidemic.

In Libya, while continuing to treat the runners' severe tendinitis, the psychological stresses created by 80-some successive days of extreme exertion and sleep-deprivation now reared their hydra heads. One was bottoming out psychologically. Another—the worst of the tendinitis sufferers— was worried about being left behind and wondered briefly about quitting. And the other member of the trio, after nearly quitting in Niger, had virtually retreated, talking to no one. This led to a fracturing of the running team’s dynamic, and soon the three were running on opposite shoulders of the roads, with one alone on one side and two runners on the other. Still, every day they continued further.

Six weeks later, by the time the runners had reached the Egyptian border, their bodies and systems were near full collapse. Tendinitis was now rampant, each of the three runners were now actively asking for strong pain medication that I had brought along in reserve for the last two days or for any severe injuries such as fractures and life-threatening emergencies.

Egypt brought with it a greater population density and far more crowded roads (meaning more vehicle threat to the runners). In addition, it had a robust security presence that implied a greater threat to us, as Egypt has seen aggressive anti-Western attacks on visitors in recent years.

For several weeks, the runners had been debating the possibility of running non-stop for the last week, treating the final, Egyptian segment as one long seven-day push. While the runners kept suggesting this scenario, Chuck and I felt they neither had the strength nor endurance left to treat the Egypt leg like an Adventure/Endurance Race, going 24 hours a day to the finish in a predicted time of seven or eight days. Additionally, we questioned whether the support crew also had the physical or psychological reserves to provide round-the-clock care. Thankfully, family and friends of the runners arrived to provide support, and generously and selflessly pitched in.

This support was doubly important, because the runners were near both physical and psychological collapse. Two men also continued to have gastrointestinal problems, and had been receiving intravenous hydration every few days for weeks. This gastro-intestinal condition also had left them with chronic diarrhea and abdominal fullness that made it difficult for them to ingest enough oral liquids to stay hydrated.

As they entered Egypt, one runner had blisters on his feet, but was responding well to care. Another runner, who had preferred self-care of his foot blisters throughout the trip, had developed a severe blister on the ball of his left foot. Within 48 hours of running a stepped-up schedule of 100-kilometer days, the blister on the ball of his left foot developed into a severe abscess with cellulitis, which covered the entire sole of his foot. I insisted on placing him on antibiotics, which he had previously refused.

More in Part 6…

photo by Jeff Peterson

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Running the Sahara, Part 4

by Jeffrey S. Peterson, MD

In Agadez, Niger—roughly the center of the journey—the runners were doing magnificently, still logging their usual mileage with little in the way of great difficulty beyond the fact they were running two marathons a day. It had become a rare day when they didn’t get in their 80 kilometers, and the need for medical care was present, but not terribly demanding.

Because we were now headed on a more northward track toward Libya, we picked up an 18-man Army of Niger attachment to provide security, owing to smuggling and rebel activity in the region. The security detail members had many of their own physical problems, and I was more than happy to provide medical care to them, out of respect to the hard lives they lead. Their diet was minimal, and their clothing not completely suited to the boiling temperatures of the day and the freezing cold nights. Across the group, I treated everything from broken teeth to cutaneous anthrax, eczema, stomach ulcers, conjunctivitis, and plantar warts. They kept me busy, but more than returned my care by keeping us safe from bandits.

A week-long sandstorm buffeted the group, and because the runners were now starting to run a long, gradual, uphill grade for hundreds of miles off-road and overland, guided by GPS with all of the running across deep and soft sand, tendinitis became a serious issue for two of the runners. To treat this more-severe pain, Chuck Dale increased his concentration of massage to the affected areas, while I began to prescribe short bursts of prednisone at different times.

As we exited Niger for Libya—being released from the country at the guard station at Madama, which has since been assaulted by rebel troops with 13 casualties and 47 hostages taken—we entered Libya, a wealthy and oil-rich nation where good, flat, smooth roads stretch to every border.

Before we could enter Libya, so that the runners could enjoy the firmer footing of paved roads, two things happened. As we approached the border-guard station at Toumou, we heard on the BBC World Service radio program that six Bulgarian nurses and a Palestinian doctor had been sentenced to death (for a second time) in Benghazi, for allegedly “infecting” several hundred Libyan children with HIV. There was clearly a lot of internal national politics about this, but it didn’t make our group, as foreigners - and especially me as a health-care provider - feel any safer.

Then, literally at the border guard station, as I was finishing my treatment of the Niger Army soldiers before they returned to their base, I was informed that one of the Libyan guards was sick and required medical attention. Given the fact that I’d just listened to the BBC, the prospect of this made my heart race and stomach churn, and tightened several other muscles in my body…to say the least.

Fortunately, the guard had severe bronchitis trending toward pneumonia, which would respond to an inhaler and the antibiotics we were carrying. For this, I was rewarded with a glass of screamingly hot, sugary, and mint-infused tea, and a firm and sincere thank-you handshake.

More in Part 5…

photo by Jeff Peterson

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Running the Sahara, Part 3

by Jeffrey S. Peterson, MD

By the time our expedition left Mauritania, it had become a daily experience to return to camp from both the morning and evening legs of the run, and find between five and 10 nomads, who had often arrived on camels, awaiting me in hopes of medical treatment. Word travels fast in the Sahara.

The run clearly now had momentum, and we literally flew through Mali. Our team was traveling eastward near the Mali/Niger border when John Davidson, the driver of our supply truck, radioed us that he had been stopped by a Tuareg woman, who'd run out of her tent carrying a baby as he'd passed through the camp. The baby had some pretty awful looking burns on its feet, John said.

We turned back to rendezvous with the supply truck. The baby, perhaps a year old and now held by its father - a Tuareg in traditional blue bubu robes and head-wrap - was horribly burned on its feet and shins. It had been burned by an overturned pot of boiling water. The water, the father explained, was from a nearby well, and they had been boiling it render it potable. The accident had happened four days earlier. Becausee of the lack of clean water, the severity of the burns, and the blowing sand, the burns were now covered in scaly, sandy, and pus-laden scabs. The burns with blisters had progressed into abscesses surrounded by cellulitis. My first thought was that this was one sick kid and likely to become even worse without aggressive management of the abscesses and treatment of the spreading infection.

I quickly went to work, creating a work area on a sheet, and had the baby's father sit with him. I then began to clean the baby's burns. It was too slow. The baby, uncomfortable with this strange man helping him, began to shriek and cry. Realizing this would take far too long, I dumped some light saline solution into a disinfected bucket, put povidone-iodine into the water, and decided to place both of the baby's feet and shins in it simultaneously to wash them. The baby, however, seeing a tub of red water (probably not all that different from the one that had burned it) began screaming bloody murder. Eventually, through a bit of manhandling, the feet went into the bucket, and the child calmed down. Forty minutes later, I could debride the dead skin (which had to be peeled off the baby's lower legs and toes), clean the wounds on both feet, and get them treated with ointments and covered with gauze.

I then gave the boy multiple intramuscular injections of two antibiotics and a tetanus shot. Through an interpreter, I showed the father how to clean and treat the wounds two to three times per day and administer the oral antibiotics that his son would need to take for two weeks. However, I still wanted to monitor the child's progress for a day or two. After 20 minutes of heated debate about whether John and I would stay behind to monitor the child's status, the father ended the discussion by saying “I'm an intelligent man, you have shown me this, I can do it. Please go with my thanks.” Realizing that we had done what we could for the child and that we were obligated to respect the father's wishes, we continued on and caught up with the runners.

A few days later, having crossed into Niger, our camp was entered by some local Tuareg herdspeople, this time four young girls. They said that their mother had given birth during the past two weeks, but was still so sick and weak she was having trouble nursing. She was becoming more dehydrated every day and could not keep any fluids down. We traveled the mile distance to the family’s camp, where I was required to obtain permission to enter from the male owner of the camp. Once granted access, I learned that the victim was subsisting on nearly-spoiled camel’s milk. Using an English-speaking Tuareg guide from our camp, I took her history and then—after politely explaining to both the male and female adults what I might be able to offer as help—was granted permission to perform a brief exam.

The woman was suffering not only from severe dehydration, but endometritis, which is a severe, post-delivery infection of the reproductive organs requiring very strong antibiotics for treatment. I returned to the camp, treated her with a battery of four antibiotics, plus some powerful anti-nausea medicine, and multiple liters of Gatorade. By the next morning, when I returned to check on her, her status had turned around. She was nursing the baby normally, and her color and skin tone had returned.

More in Part 4…

photo by Jeff Peterson

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Running the Sahara, Part 2

by Jeffrey S. Peterson, MD

Despite having on-the-ground assistance from the scientists at the Gatorade Sports Science Institute (who had joined us for the first seven days), I was reminded that there was no way anyone was able to physically train to run 4,300 miles at a pace of roughly two marathons a day; the training for that alone would begin tearing down an athlete. In our case, each individual athlete was either going to complete the run, or he wasn’t.

It was in Mauritania, despite vigilant hygiene on our part—including frequent use of alcohol hand wash, drinking only bottled water, triply-rinsed food utensils, and well-cooked and boiled food—that our team developed a significant and long-lasting outbreak of gastroenteritis, resulting in yet more dehydration. The malady would dog us for a month, circulating several times through the camp. Each bout of gastroenteritis and dehydration was treated with oral antibiotics and intravenous boluses of normal saline. It was during this time that, despite rigorous hygiene, I finally succumbed to the infection myself. Given the fact that there was no medical provider to start an intravenous drip and administer care to me, Chuck Dale offered to do the best he could with what I could teach him. Having taught many medical students previously, I had no problem with the mechanics of starting the IV. The only problem was that I had to teach him to do it on me and I felt horrible. Chuck was allowed three tries to get the IV into my vein. Being a fast learner, Chuck amazingly hit the vein perfectly on the third attempt. After aggressive hydration and rest, I was back on my feet and ready to take care of the runners and crew once again.

Having grown used to the incredible physical demands of each day—and staying constantly watchful of hydration issues—we now began a stretch of weeks characterized by remarkable progress. The runners had an amazing ability to adapt their strides to respond to repetitive stress injuries, and at the first sign of a developing problem, they would change their shoes as the initial bulwark against further injury.

Early hands-on intervention by trainer and massage therapist Chuck Dale included deep tissue massage and trigger point manipulation. In addition, a step-wise approach (modulated to the injury) of oral ibuprofen, acetaminophen, and topical lidocaine patches over ibuprofen cream —kept more complex repetitive motion damage at bay. Due to the knowledge and experience of the runners, plus the work of Chuck Dale and me, the runners didn’t experience any profound over-use and repetitive stress injuries until the last few days of their run.

Most of Mauritania was crossed on the Trans-Mauritanian Highway, a treacherous thoroughfare with narrow shoulder and speeding vehicles with drivers unaccustomed to hosting a trio of runners along its apron. Many close calls were witnessed on the road. For instance, at one point, Charlie Engle’s elbow was side-swiped by a passing vehicle, reinforcing the dangerousness of the route.

More in Part III…

photo by Jeff Peterson

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Running the Sahara

Allow me to introduce the first guest blogger at Medicine for the Outdoors. My good friend and colleague, Dr. Jeffrey S. Peterson, is an Assistant Professor of Surgery in the Division of Emergency Medicine at Stanford University Hospital. He is also the Founder and Sports Medicine Physician at Innovative Sports Medicine in Mountain View, California, and is a Medical Specialist Instructor of Urban Search and Rescue for the State of California Office of Emergency Services, as part of the Federal Emergency Management Agency. Jeff has long had a great interest in wilderness medicine, and in particular, athletic events conducted under challenging environmental conditions. In 2006 he served as a Race Physician for endurance races in the Atacama desert of Chile and the Gobi desert in China. An avid triathlete, he personally has completed two Ironman triathlons. Jeff was asked to serve as physician for the recent Running the Sahara event, in which three runners ran for 111 days through Senegal, Mauritania, Mali, Niger, Libya, and Egypt, covering more than 4,300 miles (6,920 kilometers). Jeff graciously agreed to share a bit of his diary with us, which will be presented here in six installments.

RUNNING THE SAHARA, by Jeffrey S. Peterson, MD

Part 1

ON November 2, 2006, a team of three runners stepped from the Atlantic Ocean and onto the beach at St. Louis, Senegal. Their intention was to run all the way across the Sahara desert and end at Suez, Egypt, in hopes of publicizing the water needs of the people of the Sahara to the larger world. Water in the region is running out - wells today have to be dug as much as 10 times as deep as in the past, due to a rising population and more industry depletion of the Sahara’s ancient and virtually un-recharging aquifers.

This expedition was followed by a film crew, to be made into a documentary film. I was the physician for the runners, their support teams, and the film crew. Once acclimatized, all three runners planned to cover 75 to 80 kilometers (49 to 52 miles) each day. As their physician, I was part of a larger support team that allowed the runners to concentrate on the hard work of logging their daily mileage. For all involved, the task was prodigious, and I’m happy to report that all three runners -Charlie Engle (44 years old), Kevin Lin (31), and Ray Zahab (38) - succeeded in their 6,920 kilometer (or 4,300 mile) quest.

Prior to departure, everyone was properly vaccinated and immunized for hepatitis, typhoid, tetanus, diphtheria, pertussis, and yellow fever. Malaria prophylaxis was provided, in our case Malarone, as all four varieties of malaria exist in West and North Africa. Still, several of the Africans providing services for the expedition had to be treated for malaria during the trip, using a three-day protocol of 4 Malarone tablets taken orally. In every instance, the treatment was successful.

Beginning in Senegal, extremely unhygienic conditions on the starting beach (human excrement and dead animals littered the sand), plus a mid-autumn heat wave that the runners were slow to acknowledge, nearly ended the run before it even began. Multiple film-crew members were treated for heat exhaustion.

In order to protect the runners and the expedition from succumbing to the heat, after the fourth afternoon I issued a medical edict: No running from 11AM to 4PM. My pronouncement resulted in a near-mutiny from the runners. It was on that day that I looked at expedition leader Donovan Webster, and simultaneously we said, “Looks like we’ll be home for Thanksgiving.”

Yet, remarkably, the edict held, and within days the expedition began to find its rhythm. On Day 10 of the trip, the runners notched their first 80 kilometer stretch, following proper acclimatization and a new schedule: wake at 4 AM, eat breakfast, beginning running at 5AM for roughly 50 kilometers, break for lunch and a rest, and finish the day’s run in the late afternoon and evening.

By then, we had entered Mauritania, where I continued to treat heat-related illness, mostly for Kevin Lin of Taiwan, who was not accustomed to these scorching conditions. Eventually, I was forced to provide twice-daily intravenous drips of normal saline over three days to relieve cramping and severe dehydration.

More in Part 2…

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