Warfarin?

My usual 5km while staying in Melbourne passes along
some of the leafy Malvern streets.

After six days of running about 5km a day, following two months of no running, I'm about where I expected to be in terms of cardio-vascular fitness.  My diagnosis of Deep Vein Thombosis, Pulmonary Embolism and Atrial Flutter at the start of January, had me worrying whether I would ever run again.  It was a scary time.  Now that my heart is back in sinus rhythm and I'm taking Warfarin to minimise the risk of further blood clots, running is again part of my life.

I have resumed running after injuries many times in 45 years, and generally know what to expect.  There will be two weeks, or longer if I have added a few kilograms, of feeling like a fish out of water.  After that, I will begin to feel like a runner again.  Then, the return to full fitness is generally a function of how long I had been unable to run.

The run passes by the John Landy Oval
(see post here).  

I'm mid-way through the initial couple of weeks and there's no problem with my cardio-vascular system.  I'm breathing easily and my heart rate seems to be behaving itself.  What is bothering me, is how stiff and sore my legs are.  Every morning, I feel like all my joints and muscles need lubrication as I set off.  I'm surprised I don't hear squeaking!  It's worse than I expected, and I have been tempted to blame it on the Warfarin I am taking.  If my blood is slow to coagulate, maybe the inflammation that must be occurring in my ageing and cartilage-poor joints is slower to repair and then dissipate?  Maybe there is some other side-effect?

Looking across John Landy Oval in Malvern's
Central Park.

I have searched high and low on the internet for information about the effects of Warfarin on runners, but instead of finding clues to explain my aches and pains, I have found stories of endurance athletes successfully returning to serious competition while continuing to take Warfarin.  Seems like I will have to accept the ageing process is the main culprit.

Just another 5km this morning at an easy pace, with no problems apart from the above-mentioned stiffness and soreness.

Three days and counting

Pre-dawn on Glenferrie Road, Malvern, during this
morning's run.

My right calf was still sore after yesterday's run and it feels like a muscle strain.  I can't believe I have hurt my calf in one extremely slow run, but I guess it can happen, especially as you get older.  My usual test for the severity of calf or Achilles tendon strains is to do a few heel raises.  If, standing on one leg, I can raise my heel to stand on tip-toe without pain or weakness, then I usually continue running.  That was the case this morning, so I decided to go ahead with my planned 5km run, but to favour the sore leg and to start very slowly.

Crossing Central Park, Malvern, during
this morning's run.

The calf felt tight, but survived the 5km in Melbourne's eastern suburbs.  Actually, all my muscles and joints are quite stiff, as my body rebels against the resumption of running.  I was hoping that the walking I had done in the last two months would have made the transition to running easier, but it's still difficult.  However, I know that if I can persevere for another week or two, I will be moving more easily, and the runs will be more enjoyable.  Having said that, I already feel healthier as a result of running on three consecutive days and look forward to losing a couple of kilograms I have added since Christmas.

I was conscious of my breathing and heart the whole run, but my breathing was controlled and my pulse remains regular.  I'm gradually getting more optimistic about my prospects, but mentally preparing myself for a set-back should it occur.

So far so good

Second from left, with the University of Melbourne
Cross-Country team in Canberra for the 1979
Intervarsity Championships.

It was with more than a little trepidation that I set off for this morning's 6km walk/run after supervising the 6:00am Trotters' track session at the Terrigal Haven.  I walked the first 500 metres, which included a solid hill, then jogged a few hundred metres before walking up a second, steeper and longer, hill.  So far, so good.  Once at the top, on Scenic Highway overlooking Terrigal, I decided to jog the remaining 4.5 kilometres of the 6 kilometre course if I felt OK.

I was very slow, and felt very unfit.  At one point, I was passed by ultra-running friend, Darren, who was himself running very slowly as he came back from injury.  How slow can you go, and still be running?  My joints creaked and my chronic bad knee hurt, but my breathing remained steady.  All the time, I was examining my heart and chest with my brain, looking for signs that something was amiss, but nothing happened.

When I reached the last few small hills, hills that I had originally intended to walk up, I chose to keep running.  I felt a little reckless, but was gaining confidence, that so long as my breathing was comfortable, I was not stressing my heart.  Back at The Haven, I reached my car and stopped running.  It hadn't been any tougher than other first runs after two months off, and I felt a glimmer of hope that I was on the way back to recreational running, if not competition.

Walking and pondering

The backlots of McMasters Beach on this morning's walk.

I walked about 10km this morning in misty, drizzly, and almost autumnal weather along some less-travelled roads and trails around nearby McMasters Beach.  Walking gives more time to look at your surroundings, and I've enjoyed a closer examination of the forests and properties that I often pass more cursorily on the run.  It's all relative, of course, with walking better than running, and running better than biking, if you want to absorb your environment.  All are better than driving.

The gravestone of Allan McMaster, the first European
settler in the area named after him.

Another advantage of walking, for me at least, is that it is the best time for thinking.  I'm a stroller rather than a power walker, and the gentle perambulation seems to stimulate my analytical brain cells.  As I walked this morning, experiencing no breathlessness or heart palpitations, I wondered about the chances that my heart problems were behind me.  If not, how would the return of the Atrial Flutter (AFl) be triggered?  By running too hard?  And if it was triggered, would it suddenly be as debilitating as it was before the Cardioversion, or would the onset be slower?  What were the chances of reversion, and what were the risk factors?  Wouldn't the cells through which my heart was passing the errant electrical pulses still be there, just a dormant pathway waiting to be reactivated by stress or some other trigger?

Umbrellas were optional on a drizzly morning walk.

There was lots to think about, inconclusively, and I returned home to do some more Googling.  Nothing I could find gave me more certainty, but there were clues.  One study in particular, of men a similar age to me, found that 55% had recurrent AFl within six months of their Cardioversions.  Underlying heart disease, previous episodes of AFl, and enlarged left atriums all seemed to be statistically significant factors in those who reverted.  I'm not conscious of previous AFl events, and my cardiologist found no evidence of heart disease, but he did find "mild Left Atrial dilatation".

Cockrone Lagoon on an autumnal morning.

Other studies have found enlarged left atrial size to be more common in long-term endurance athletes, than others of a similar demographic, and that this seemed to be associated with great incidence of Atrial Fibrillation (AF) and AFl.  So, it seems reasonable to assume I remain at significant risk of reversion.  The great unknown for me, though, is whether the enlarged left atrium was the key factor in the development of my AFl, or was it the Pulmonary Embolism (PE) placing undue pressure on the heart's function that was the trigger.  Although I'm probably stuck with the enlarged left atrium, the PE should be gone soon, if not already.  Does that mean there's a good chance I won't have the problem again?  Probably not, but only time will tell, although there will never be a point at which I can say there is no further risk.

Eggshells

Cockrone Lagoon on this morning's walk.

As I approached the first hill on my walk this morning, I felt my heart was racing in anticipation of whether it would start racing as my effort increased.  Then, as my cardiovascular system worked harder on the steepening grade, I was constantly assessing my body's reaction.

Part of my walk through McMasters
Beach this morning.

The symptoms I had experienced when walking up steep hills prior to Monday's Cardioversion included breathlessness, lightheadedness bordering on fainting, a hollow pressure in the centre of my chest and, as described on some medical websites, a real feeling of dread or impending doom.  There would be a sort of tipping point, where in a matter of seconds, I would go from the familiar feelings of mild fatigue associated with walking up a hill to a sense of the clutch slipping and my internal engine spinning faster and faster in a fruitless attempt to keep my body functioning.  It wasn't a pleasant experience, and I was hoping, rather than expecting, this morning that the Cardioversion had done the trick and my Atrial Flutter was gone.

Bounty Hill steps on this morning's walk
through McMasters Beach.

Since the procedure on Monday afternoon, it has been hard for me to tell whether or not the Cardioversion has made a difference.  I had been taking it easy, and a head cold, blocked sinuses, and a mild headache have made it hard to judge my overall well-being.  However, regular pulse-checking, and a vague feeling that my body was working more efficiently, have been encouraging signs.  The possibility of reversion to Atrial Flutter remains very real, though it will diminish over time, but it will be a while before I stop worrying about the consequences every time I start breathing harder on a walk or run.

Pumice stones on McMasters Beach which
have floated more than 4,000km from an
underwater volcanic eruption north of
New Zealand.

I didn't push it too hard on the hills this morning, and so far as I can tell, my heart is still beating normally.  The 6 kilometre walk passed easily enough, finishing with the bonus of watching a pod of dolphins gambolling just outside the shore break on the Copa beach.  I would like to think it was a good omen, but I don't believe in such things.  Now I need to work out a training plan that will gradually return me to running in a methodical way.  Such a plan will help prevent me trying to do too much too soon, if I feel that things are going well, but I also need to have the common sense to back off the plan if it appears too optimistic as time passes.

Googling the future

Representing Croydon Harriers in a National League
3000m Steeplechase (4th, 9:43.8) at Brighton, England,
in May 1975.

Around 3pm yesterday, I had my DC Cardioversion (DCC) and Transoesophageal Echocardiogram (TOE).  Apparently the DCC went smoothly, and my heart is now beating regularly again (Sinus Rhythm).  It's a very routine procedure these days (you can see a video here), and the anaesthetist referred to it comfortingly as a "barbecue" as he prepped me.  I only saw the hospital cardiologist once, when he shook my hand before I went under, and I didn't get any feedback later apart from the discharge nurse who said my heartbeat was stable in Sinus Rhythm.  On the assumption that "no news is good news", I'm guessing the TOE, with which they were looking for clots and flaws in the heart structure, didn't reveal anything untoward.

I now have a follow-up appointment with my cardiologist in three weeks time, but don't really have any guide as to what I can do, or not do, before then, other than being told to take it very easy today.  Consequently, I have been Googling extensively, particularly on the subject of returning to running after DCC.

Competing in the VMC Marathon (2nd, 2:31) at Tyabb,
Victoria, in June, 1976.

There's no shortage of papers identifying long-term endurance athletes as having a much higher risk of Atrial Fibrillation or Flutter than people of similar age, but it's hard to determine what is the outlook for those returning to the sport after treatment.  There are opinions expressed that they are more likely to have future heart and related problems, but no studies I could find.  Every individual is different, and there would be few people in the world who have trained and run endurance events over as many years as me, so there are unlikely to be any specifically relevant medical studies, anyway.

A good friend and long-time endurance athlete, Bill, suggests I accept my lot and cut back to roughly an hour's non-competitive running a day and be thankful that I can do that.  Time and energy freed up can then be devoted to other interests, such as writing.  I can see the sense in this suggestion, but am not yet convinced that it is the best course for me.  I'm still in the "Bargaining" stage referred to in a previous post, and want to believe there's some middle ground.

Comparing hamstring flexibility with Bill after the VAAA
Marathon Championship (4th, 2:22) in March 1983.

Part of the problem is determining what sort of running increases the risks for me.  Racing, and training to race, definitely generates more heart stress than running as a non-competitive recreation.  A race gets my adrenalin pumping and I always perform significantly better than I could manage in a non-competitive time trial. Likewise, upcoming races, get me to training harder and longer than I probably would otherwise.  I love competition and the preparation for races, but believe I could live without it, if it lowered my risk of further heart problems.  I think I could be satisfied with moderate short runs during the week, the regular Saturday Trotters run without getting too competitive, and a relaxed long trail run on a Sunday.

I'll continue walking for the next couple of weeks and then try some jogging just before I see the Cardiologist.  The statistics show that DCCs are 99% successful, but have a 50% reversion rate.  I'm assuming that I will be one of those 50% reverting, and my Cardiologist has already said he thinks I may ultimately need a Catheter Ablation.

Over with

1982 Montreal International Marathon (46th, 2:29).

Motivation was low today, and after several days with less sleep because of early morning commitments, I stayed in bed procrastinating.  Not really sleeping, just dozing, with a mild headache giving me another excuse to dally.  Maybe it was my imagination, but I sensed my heart was racing some of the time, even when lying in bed, and that wasn't good news.

Eventually I rose, watched one of my favourite political programs over a late and light breakfast, and headed out for a 5km walk on a very warm and sunny morning.  The walk started with a moderate hill and I was a little disturbed to already feel out of breath and conscious of my heart racing.  After another hill on which I again struggled mildly, I had to stop and hold the railing on a short flight of steps and even toyed with the idea of returning home.

The leading bunch in the 1983
Victorian Marathon Championship
(4th, 2:22).

I feel my condition has gradually deteriorated over the six weeks since I was first diagnosed with problems.  Just a few days before my first doctor's visit, when I was already dealing with the symptoms of breathlessness and a racing heart, I had been able to run an easy-paced 30km along mountain trails without major issues.  It seems inconceivable that I could do that today.  As I walked this morning, it was pleasing to know my DC Cardioversion was scheduled for tomorrow, and that I wasn't still waiting for the originally scheduled specialists appointments in two weeks time.

I haven't been optimistic about the permanency of the cardioversion, but feel more hopeful after a discussion with a doctor friend last night at a social gathering.  She saw no reason why a cardioversion might not be a long-term solution and cited her own father as an example.  Nevertheless, I think it's prudent to be a little cautious.  I don't feel anxious about the procedure, though that may change as the hour approaches (2:30pm tomorrow afternoon).  I just want it to be over with.

The episode on the stairs passed after a minute or so, and I decided to continue with my walk and completed it safely, despite a few more minor occasions of breathlessness.

In a perfect world, the cardioversion will immediately improve my quality of life as my heart returns to normal, but it's not a perfect world.  Fingers crossed.

1:1 AV Conduction

One of my heart rate peaks, as measured by the
Holter Monitor.

Late today, I had my Cardiologist appointment to discuss my recent Echocardiogram and Holter Monitor results.  He was a fit-looking guy in his fifties and was sympathetic to my plight and my desire to resume running.

It seems that my efforts to give them something to look at while I was wearing the Holter Monitor a week ago were more successful, and risky, than I thought.  The two episodes I had of palpitating heart and lightheadedness while walking up a steep hill, matched recorded instances of my heart rate reaching around 230 beats per minute.

Diagram of the heart showing the path of the macro-reentry
circuit (wavy red line).

Normally, the upper (Atrium) and lower (Ventricle) chambers of the heart beat at the same rate.  However, with Atrial Flutter (AFl), the Atrium beats significantly faster than usual because of a sort of electrical short-circuit (macro-reentry circuit) and a proportion of these faster beats stimulate beats in the Ventricle.  The rate of conduction is determined by a physiological barrier between the chambers and is usually 2:1 for people with AFl (and sometimes 3:1 or 4:1).  When I walk too hard, or run, my ratio appears to change to 1:1 where every superfast beat in the Atrium stimulates a corresponding beat in the Ventricle.

One medical website I found says "Atrial flutter with 1:1 conduction is associated with severe haemodynamic instability and progression to ventricular fibrillation", so I need to keep my heart rate lower until I get treatment.  This diagnosis was a little more worrisome than I had anticipated.

The cardiologist is scheduling me for an Electrocardioversion within the next week aimed at resetting my heart's electrical system (in layman's terms) using externally-delivered electrical stimulus (the paddles, or similar).  The cardiologist warned that this procedure may not yield a long-lasting solution, so I shouldn't get my hopes up.  I will be able to resume my running, but the AFl could return, and I will have to stop again.

If that happens, then when I'm no longer considered at risk of further Deep Vein Thrombosis or Pulmonary Embolism, they will try a Cardiac Ablation using a catheter inserted into the heart through the femoral vein to cauterise the tissue where electrical short-circuit is occurring in the Atrium.  This procedure has a high success rate and provides a longer-lasting solution, but I know everybody is different and I'm not counting my chickens yet.

I walked about 5km today, with no significant hills, and felt fine.

[Disclaimer:  I have no medical qualifications at all and there may be significant errors in this blog post.]

Psychological effects

5:30am in Terrigal and the first Trotters begin checking
for the Saturday run or walk.

Like most Saturdays, today started with a 4:30am alarm and arrival at the Terrigal Surf Club fifty minutes later to join my Trotters club-mates for our weekly 6:00am run.  Only, I'm not running at the moment......but I'm not alone.

I have never analysed the stats, but my guess is that you could divide the Trotters population into quarters.  One quarter are fit and running well. Another quarter are running, but carrying an injury.  A third quarter are running, but coming back from injury, and the final quarter are unable to run because of illness or injury, some permanently.

Kurrawyba Avenue in Terrigal was on
my walk route this morning.

Many in that final quarter are not only dealing with pain associated with their ailment, but also dealing with the psychological impact.  Fortunately for me, there's no physical pain, but I do feel the psychological effects.

The easiest to deal with is the loss of routine.  Like most serious runners I have always relied on routine to help me fit training in with family and other commitments, and the loss of routine can be destabilising and depressing.  Replacing running with some other form of exercise, if at all possible, and using any additional spare time to work on other useful or meaningful projects has generally worked for me.

One of the most challenging impacts can be the loss of identity.  The thing that most people know about me is that I'm a reasonably good runner.  Although I like to think there are other dimensions to my character, I do also see myself as a runner.  In the last month, in my own eyes, and the eyes of those around me, I am morphing from a serious masters athlete to a senior citizen with cardiovascular problems.

Sunrise over Terrigal.

Along with the loss of identity can go a loss of self-esteem.  The podium finishes that I enjoyed in the past, and these days, just keeping up with younger runners, builds self-confidence.  Absorbing challenging training regimes and successfully planning and preparing for major races also contributes positively to self-esteem.  The longer I am unable to run, the less happy I am with myself, even when there's nothing I can do about it.  And the worse I feel about myself, the more likely I am to over-eat and put on weight and so the downward spiral goes.

I also have real fears that being unable to run for an extended period of time will lead to a deterioration in my overall health.  Of course, it seems likely that running caused my current cardio-vascular problems, and I recognise that running is not a guarantee of good health.  However, I have no doubt that the fitness gained through running has improved my quality of life and fended off other ailments that beset my demographic.  I now worry that all that good work will be undone if I can't get back to serious exercise.

Early morning stand-up paddle boarders.

Finally, I have always found that running refreshes me and helps me deal with life's stresses.  This was certainly true during my working life, where the morning run seemed reset my body clock and wipe away (or at least diminish) problems.  Maybe it's the lack of oxygen getting to the brain, but I always found it difficult to worry about things, or even do relatively simple mathematical calculations, while on the run.

While most of my club-mates ran this morning, I walked a comfotable 6km.  I'm still in a holding pattern.

Finding the boundaries

Coast Road in North Avoca tested my limits this morning.

The Holter Monitor involves having five electrodes, connected by wires to a battery-powered recording unit a bit larger than a smartphone, stuck to various parts of my chest for 24 hours.  The device will record my heart activity and I'm supposed to note the time of any periods when I feel breathless or notice heart palpitations.  I was worried the electrodes would become detached while I slept, but the technician did a good job of taping them down, and they were still there this morning.

Wamberal Beach from my walk this morning.

The Respiratory Specialist yesterday, while not encouraging me to run, implied that it wasn't necessarily dangerous, just that it would be difficult and uncomfortable.  I didn't want to confirm his prediction, but did want to get my heart-rate high enough today to provide good evidence of the occasional problems I have experienced in the last month.

Thursday, as usual, started with supervision of the 6:00am track session at Terrigal Haven on what was a beautiful sunny, and a little humid, morning.  I watched the twenty or so runners go through their paces (seven times 800m with a minute recovery between each) in the 45 minute session before they headed off to their breakfast coffees, or work, or to get their children ready for school, or all three.  I always feel a bit lazy, being retired, that they have to rush off while my day continues at a more leisurely pace.

Terrigal Beach this morning.

I returned to my car, donned my radio and headphones, and set out on a 7km walk that would include several hills I thought steep enough to test my impaired cardio-vascular system.  Rather than my usual stroll, I walked a little more briskly to encourage the symptoms.  The first significant hill climbs up the Scenic Highway out of Terrigal and I fully expected to succumb to breathlessness as I maintained a good pace, but I was surprised to reach the top without a problem.  It was good that I was feeling better than expected, but bad that there was no discernible heart arrhythmia for the Holter Monitor to record.  A little nonplussed, I continued on down Tramway into North Avoca, circled through the beachside streets and tackled the second steep hill, Coast Road.  This hill is steep enough to always be a serious challenge when running, and I couldn't envisage walking briskly up it without testing my current limits.

Terrigal Haven this morning.

Sure enough, after about 100 metres of serious climbing, I felt my heart racing and my blood pressure dropping.  I had to stop for fear of passing out, and just stood quietly for a minute, ready to sink gracefully to the side of the road if necessary.  After a minute or so, my equilibrium was restored and I continued on.  However, a few hundred metres later, at another short sharp little pinch, the same feeling enveloped me and I had to stop and stand still for a short period, again ready to cushion my fall to the road if I fainted.

It was encouraging, though, that once equilibrium was restored, I felt fine and could continue on at a good pace so long as the grade wasn't too steep.  I walked another couple of kilometres down into Terrigal before returning along the beach promenade to The Haven and my car, where I noted the times I felt unwell for the doctor to compare to the heart monitor.  I'm sure he will have something to look at now.

Perspicacious medicos

Cockrone Lagoon, between McMasters Beach and Copa,
and near our home, is one of my favourite places to walk.

I walked 5km this morning, and although not as bad as yesterday, still felt more breathless than has generally been the case in the last few weeks.  Maybe I've just had a bad couple of days.  I have read stories on the Web of runners coming back from Pulmonary Embolism (PE) who have bad patches.  Nevertheless, I was pleased I had an appointment scheduled for later in the morning with a Respiratory Specialist to get an expert opinion on my situation and some answers to questions.

Cockrone Lagoon.

As it turned out, the Specialist's opinion was that the worst of my Deep Vein Thrombosis (DVT) and PE was past, and that as long as I was taking the anti-coagulant, Warfarin, my prognosis was good.  In fact, if my heart wasn't an issue, he would have been OK for me to resume running, which was good news.  He spent some time checking my pulse, and said he was sure that the breathlessness I had been feeling was due to my heart which was beating irregularly, averaging about 60-70 beats per minute compared to my usual resting rate of low 40s.

Cockrone Lagoon.

He seemed keen that I see the Cardiologist (my appointment is four weeks away) as soon as possible and actually tried to get me an appointment today (they are in the same building).  I think the urgency was driven by his desire to help get me running again rather than any concern about my current condition, although he didn't actually say that.  He told me he was training for a triathlon, confirming to me the wisdom of getting a Specialist recommendation from my sports medicine friend, Dr Jon.  In my experience, medicos who participate in endurance sports have a much better understanding of obsessional distance runners such as myself.  They know how much it means if we cannot run, how much we test our physical limits, and how prone we are to ignore pain.

He prescribed another heart test, a Holter Monitor, and told me to call the Cardiologist when the results were available, mention his name, and I should be able to get an earlier appointment.  I called to arrange the test, and because they had a cancellation, was able to get an appointment this afternoon.  I'm now walking around with electrodes attached to various parts of my chest and connected to a battery powered recorder on a waist belt.  I have to note the time of any breathing or heart events I notice in the next 24 hours and return the device tomorrow afternoon.  Hopefully, I'll be able to get an appointment with the Cardiologist next week and make progress on the heart problem.  I sensed the Specialist I saw today thinks the heart arrhythmia will be correctable, but time will tell.

Physical introspection

Quarry Track in Bouddi National Park.

Motivation was low today and I down-scaled my originally intended 15km road walk to one of 10km including bush trails and beach.  Part of my ennui stems from the feeling that I could do more exercise than is currently wise.  The 10km walks all week have been completed easily and I haven't strayed into the "Amber Zone" where I begin gasping for breath and feel my heart pounding.  Maybe this is because I'm getting better at managing my impaired cardio-vascular system, or maybe it's because it is gradually improving.

While not forcing the pace, I walked steadily at around 5km per hour, and after circling round the southern side of Cockrone Lagoon, followed roads and a fire-trail steadily upward to the highest point in McMasters Beach.  As I walked I found myself constantly reviewing how I was travelling, especially up the steeper climbs.  Was my breathing steady or was it becoming more laboured?  Was my heart racing?  Was that slight ache in the back of my left chest heart-related?  Was I at all light-headed?  All runners coming back from injury, or tapering for a race, will recognise this nervous physical introspection phase where every niggle and sign is examined to see if it is something more ominous.

View from Bombi Point in Bouddi National Park.

I continued walking towards Little Beach, then on reaching a trail junction, decided to change my planned route and followed the Quarry Trail up into Bouddi National Park.  It's a trail I have run along a few times over the past ten years, but it's not part of my regular training routes.  One advantage of walking, as opposed to running, is that you get more time to look around and appreciate your surroundings, and once up on the plateau, this trail passed through some beautiful and peaceful woodland, disturbed only by an encounter with Joe and Deirdre, some Terrigal Trotter friends out on a long bush run.

View from Bombi Point in Bouddi
National Park.

I was starting to enjoy my walk and decided to follow the Bombi Point trail, a dead-end trail that I have often passed, but never followed, when running through the Park.  After a gradual 1km descent on the sandy track it ended at the top of a precipitous cliff offering spectacular views along the wild coast and out to sea.  A heavy swell was crashing into the base of the cliffs and the spray was rising high into the air, though still many metres below my vantage-point.  It was a breath-taking location, and a little scary closer to the cliff edge.  I will be including it in future walks and runs.

My route home followed some familiar and lovely single track winding through sheltered and mossy rainforest, and then after some road walking, finished along the beach from McMasters to Copa.  It was low tide which makes the walking easy and there were lots of holiday makers out enjoying the Australia Day weekend and the end of summer vacation for many.

I have discussed in previous posts ("Getting out the door" and "Small explorations") the value to me of training somewhere more interesting when you have one of those days when you just can't be bothered, and today proved the point.  It wasn't quick, and there was a bit of dallying here and there, but I covered 13km without trouble.

“On Death and Dying”

Looking towards Avoca Beach from North Avoca
during today's walk.

Serious runners with more than a few years behind them will be familiar with the psychological impact of injuries.  As discussed in my post titled "Punctuated Equilibrium", major injuries have derailed my running and racing plans and, perhaps, permanently inhibited my running potential.  Even soft-tissue injuries that later healed completely, were devastating when they thwarted plans for a big race. In dealing with such injuries, to some degree or another, I have recognized my own emotional progression in the stages identified by Elizabeth Kubler-Ross in her seminal work “On Death and Dying” - Denial, Anger, Bargaining, Depression, Acceptance.

With my recently-diagnosed health problems - Deep Vein Thrombosis (DVT), and associated Pulmonary Embolism and Atrial Flutter - I can feel myself travelling the same road again.  The territory is familiar, though maybe amplified by the potential whole-of-life impact of the diagnosis, and I am confident I will eventually reach the "Acceptance" stage.  In the meantime, I'm tracking my progress through the earlier stages of the process.

Avoca Lagoon.

Denial.  When, during the Terrigal Trotters' Santa Run just before Christmas, I first experienced unusual shortness of breath, palpitating heart and excessive fatigue, I didn't believe there was a serious problem.  It was warm and humid, I had been training hard, and I was wearing an Elf suit.  Worst case, I had picked up some kind of bug, which would pass in a few days.  I was still in denial a week later, but finally accepted something was seriously wrong when I struggled badly a week later in the monthly Trotter's 10km Time Trial.

North Avoca Lake Track.

Anger.  After the diagnoses, it appeared likely the originating DVT resulted from failing to drink enough following a warm long run before having a longish nap.  Low blood pressure, viscous blood, and inactivity combined to produce clots.  No doubt other risk factors were involved, but addressing these two may have prevented the problem.  I kept returning to the day in question and asking myself why I didn't stop at a store on the way home to buy a drink, as I would usually do, and why I recently started having post-run naps when for decades I had "pooh-poohed" the idea?  Why had the heart and lungs that had served me faithfully for 45 years of serious running now let me down?  Shouldn't the years of training have made them more resilient?  Would things have been different if I hadn't recently changed my shoe brand after decades with Nike Pegasus?  Overnight I had moved into a new demographic.  I was now discussing heart issues with my step-mother as an equal when a month earlier we had seemed to live on different health planets.  There was also anger that I could no longer exercise with the same intensity, perhaps impacting my health in other respects.

Avoca Lagoon.

Bargaining.  I have kept Googling, reviewing the medical websites and the experiences of others, and theorising on the quickest acceptable way to return to running.  Positive snippets of information are seized on, but often discounted or disregarded after rational consideration.  If I have larger lung and heart capacity than the average human, then even if they are functioning sub-optimally, I should be able to jog conservatively when others would be limited to a walk?

I'm still in the "Bargaining" phase because I don't have good information about my prognosis yet.  No doubt, I'll keep coming up with hypotheses that get me back to running sooner rather than later, but know that expert opinion based on my particular situation is needed, and that feedback will only start with my specialist appointments at the end of February.  I periodically experience some symptoms of the "Depression" and "Acceptance" phases, but feel those phases are yet to come, and I will discuss them in a future post.

Another 10km of easy walking for exercise today following the early morning track session at Terrigal Haven.  I tried walking somewhere less familiar to make it more interesting and that seemed to work.  If I want to keep walking 10km each day, maybe I'll have to drive to some varying locations.

Punctuated equilibrium

Hanging upside down was one of
the treatments I tried for my chronic
back injury.

When I was in my running prime, I gave little thought to athletic decline.  I knew many veteran (masters) runners and recognised my potential as a runner would decline as I aged.  However, I never thought much about the process.  If anything, I expected the decline to be a smooth glide path.  Each year would see slightly slower times for benchmark distances and I would be chasing podium places as I entered each new age group.  It was a naive and simplistic view of the process, and my only defence is that these issues seemed remote and I didn't give them sufficient thought.

Now, with ageing parents and my own ageing body, it has become obvious the process of ageing and athletic decline is more akin to the evolutionary biology theory of "punctuated equilibrium".  This postulates that, over time, long periods of stability with little change are punctuated by events causing significant change.  Rather than being on a gradual descent to our ultimate demise, or the end of our running career, we have periods, often lasting years, when our abilities and capabilities remain relatively static.  As runners, these stable periods may include various soft tissue injuries and oscillating fitness, but our basic capabilities are essentially unchanged.

Looking towards North Avoca from Avoca Beach
during this morning's walk.

Significant events for runners are those injuries from which we never really fully recover, despite how hard we train.  There were no more Personal Bests for me after a back injury (spondylolisthesis) sustained  in 1979 brought to an end the steady improvements I had seen in the preceding years.  Likewise, a serious knee injury in 2006 meant a lot of time off running and a limit on training load I could sustain in subsequent years.  I could plot other significant injuries over the years that have also had a lasting impact on my running capability.

Looking from Copa, low cloud covers Mount Bouddi
during this morning's walk.

Now I'm trying to reconcile myself to the capability change that will result from my Deep Vein Thrombosis and associated Pulmonary Embolism and Atrial Flutter.  I'm still in the midst of this "event" and don't know the level of capability I will emerge with, but it will almost certainly be less.  Goals will have to be recalibrated, or frustration will build.  I'm not reconciled to these changes yet, but can sense I am in the midst of the process and will eventually accept what must be.

This morning, I walked a comfortable 10km in misty rain beneath low cloud.  It was a nice change from the relentless summer weather of the last three weeks.

When to run again?

My walking route this morning took me through the
Avoca Beach Markets.

When I went to bed last night I had decided that today's exercise would include some light jogging.  It's not so much that I'm desperate for an endorphin high, or even the satisfying fatigue that follows a run.  It's more that I was very fit four weeks ago and I can feel that condition ebbing.  I know these feelings are familiar to all injured runners, but this time around I'm conscious that a miscalculation on when to start running again could feasibly have fatal consequences rather than just a setback in recovery time.

Avoca Beach Markets.

So, this morning, while enjoying my cup of decaffeinated coffee, I surfed the Web and pondered the most rational approach to a return to running.  I don't want to take stupid risks, but I don't want to be too timid either.  Finally, I decided to just walk 10km today and use the time to work out a rational strategy.  I do my best thinking while walking.

The first conclusion I reached was that the Deep Vein Thrombosis (DVT) diagnosed seventeen days ago was still at significant risk of throwing off small clots that could impact my lungs and heart.  Many sites on the Web indicated a minimum of four weeks and usually six weeks for DVT's to resolve themselves.  I should probably wait another three weeks and possibly an "all clear" from another ultrasound exam of the lower right leg before resuming jogging.

Avoca Beach Markets.

The second conclusion I reached was that my exercise, whether walking or running (when the time comes), should be at a pace which does not push my heart/lungs into what I'm calling the "Amber Zone".  Twice during today's 10km walk, near the top of steep and longish hills, I could feel myself beginning to struggle for breath and an unpleasant sort of pressure (not pain) building in the base of my chest as my heart began to race.  It was as though the clutch was slipping and no drive was being transferred from the engine to the wheels.  This was the same feeling I had when running faster up hills just before being diagnosed with Pulmonary Embolism (PE), so I'm becoming familiar with it.  I didn't have to stop walking for the sensation to abate today, but did need to slow right down to a dawdle.  I would define the "Red Zone" as being the need to stop and sit down, and I have not reached that point yet, nor do I want to.

Avoca Beach Markets.

Like most chronic injuries, I feel like I'm starting to get a handle on how to manage it, but know it is not wise to look for the "edge of the envelope" as has been my inclination in the past.  I also know that, even after the DVT has resolved itself and the clots in the lungs are no longer an issue (which could take months), I will still likely need some sort of medical procedure to address the Atrial Flutter problem before I can start running hard again.  Patience!

[I have posted my Post-DVT Training Diary here, or it is accessible from the Links menu at right.]

Fibrillation or flutter

Part of my walk around Copa today

I wasn't really anticipating any good news when I had a long consultation with my GP today, just a summary of the tests so far and referrals to some specialists.  If anything, I came away a little more positive.  She confirmed that all of the blood tests for more sinister underlying conditions had come back within normal range, and provided more detail on the cardiac tests and leg ultrasounds.

Apparently, the cardiologist diagnosed Atrial Flutter (AFl) rather than Atrial Fibrillation (A-fib) as being my heart condition, and according to the GP, this is the better diagnosis to have.  I gather A-fib is chaotic disorganised beating of the Atria while AFl is regular, but way too fast, beating of the Atria and may be a little easier to treat and sometimes stops of its own accord.

Looking north from Captain Cook Lookout
during today's walk

The leg ultrasound report found "some occlusive thrombus in one of the peroneal veins from 7cm below the knee crease to 20cm below".  The GP says her starting theory would be that the thrombosis in the leg has thrown off small clots that have impacted both my lungs (Pulmonary Embolism) and heart (AFl), but has referred me to a respiratory specialist and a cardiologist to try and confirm the diagnosis and prescribe treatment.  In the meantime, I continue with the Warfarin anti-coagulant.  The earliest specialist appointments are six weeks away, but I guess the fact that I'm not seen as an urgent case is a good sign.  It probably means, however, that my exercise is going to be limited to walking until at least the end of February and any prospect of returning to serious marathon training in time for the Gold Coast Marathon in July is remote.

Looking south from Captain Cook Lookout during
today's walk

I won't abandon the marathon goal until I speak with the specialists, and dearly want to resume regular running.  However, I am already mentally more focussed on the need to be fit for my next planned adventure, a 3500km southbound hike along the Appalachian Trail from Maine to Georgia in the eastern US starting in Autumn (October) and finishing in the Spring (March).  I know there is a possibility that this too could be scuppered by my current health problems, but I'm trying to be optimistic.

I walked about 8km today, not particularly quickly, and felt fine the whole way.  I gather that regular leg use is recommended in the treatment of Deep Vein Thrombosis, so being able to walk 8km without pain or other problems must be a good thing, I reckon.

Little (Beach) hiccups

Looking towards McMasters Beach

For today's blog post, I was planning to write about one of my favourite local 10km runs, the Little Beach circuit, and set off to walk it with my camera.  This was to be my longest walk since I stopped running two weeks ago, but I reckoned that provided I didn't push it I would be OK.  Going clockwise, the first section of this course goes along the beach to the village of McMasters Beach.  It was a beautiful sunny Sunday morning and the beach was busy with holidaymakers walking and jogging its length.  The fairly steeply sloping beach meant walking up on the softer sand to avoid getting my shoes wet by the occasionally larger incoming wave and I could feel I was working harder than if I had been walking along a road.

McMasters Beach

I didn't slack off, keeping up a good pace and left the beach at McMasters to climb a steep concrete path that would take me towards Bouddi National Park.  I walked quickly up the short hill, but near the top began taking huge gulps of air and could feel my chest pounding, as it had done on a few runs in the week before being diagnosed with Pulmonary Embolism (PE).  Not good!  Only a month ago, I would have run up this hill without even noticing it.  I slowed to strolling pace and decided to cut my walk short and head home.  On more gradual gradients at an unpressured pace, I was fine and got home without further concern, but the whole episode was quite depressing.  Not knowing whether the problem is the PE or Atrial Fibrillation (AF) or both, and what can be done about it, just compounds the problem.

I know I just have to be patient, and although I'm determined to keep walking up to 10km a day, this morning's episode reinforced the need to avoid pushing the pace.  According to my Web research, there's no standard time for blood clots to dissolve, whether in the legs or lungs and I must resign myself to several more months of limited exercise, at least.

Cockrone Lagoon at the end of today's walk

Today was also the day on which the 64km Bogong to Hotham race was held in the Victorian Alps, an event I had been training for before the PE hit.  Several times during the day, I thought enviously about where the runners would be on the course, and that hasn't helped my mood.  I have a consultation scheduled with my GP tomorrow, and although not expecting any new revelations, I do anticipate getting referrals to specialists where I'm hoping for more clarity about my condition and prognosis.  However, it won't be a speedy process.