PSA: Rhabdomyolysis

It's more than simply dehydration

What is below happened some 5 years ago and was printed (shorter version) in Dirt Rag in early 2017, eventually the entire version here was on their website in the summer of 2017. If you’ve never heard of Rhabdomyolysis, know that most of us haven’t and is why I’m posting this here.

Share it far and wide to raise awareness.

Best,

James

Bikepacking Berryessa: Rhabdo and Pushing the SOS Button

We woke inside our tents under a cloudy, early morning sky.  The cover from the sun was welcomed, knowing we had a hard ride in front of us, while also being unsure of what the trail conditions would be like on this backcountry route. The Fiske Peak loop, in the new Berryessa-Snow Mountain National Monument, was our morning itinerary; it links up County Road 40, Fiske Creek Trail, Fiske Road, and Blue Ridge Trail. At 16.5 rugged and remote miles, local beta suggested it would take upwards of five hours to complete the route.  What?

We fueled up with breakfast calories and then went down to Fiske Creek to filter water and fill our bottles and hydration pack.  At the creek, we drank some water while pumping, and pumped additional grimy creek water through the filter back into the bottles to top them off.  I had approximately 91 oz of water and electrolytes.  Steve had about 110 oz of the same. 

Time:  7:50 a.m.

Up Country Road 40 we went, a slow pedal to ease into the first section of the ride: 800+ feet of elevation in a little over two miles.  The pace was not too strenuous, though a few spots required a little extra effort.  Not seemingly too long into it, we reached the turn-off for Fiske Creek Trail on the left. 

Rolling along through the oak forest with golden grasses as the floor, we enjoyed the natural beauty surrounding us.  The trail itself, for the first 1.5 miles down to the creek, was able to be ridden, though was a little on the unkempt side of things.  Nevertheless, we were smiling and having a good time. 

At the creek, things began to change.  Much of the trail was overgrown, though we were able to pedal sections.  Bushwhacking, sidestepping poison oak, pushing and pulling our bikes, searching for and finding the trail as it crisscrossed a mostly dry creek bed, lifting our bikes over and through rocks were the primary activities for 2.5 miles, which took us about 1 hour and 20 minutes, according to my SPOT device.

I arrived to Fiske Creek Road and let out a holler of relief and happiness all in one, glad to be out of that creek bottom.  We stopped and rested a bit; eating and drinking before the 2+ mile climb up a 4x4-required dirt road to the “Helipad,” a flat spot some 1200+ feet of elevation up at the end of the road and below the ridgeline.

Off we went.  Both of us being ones who like climbing, we were content pedaling and taking in the views, and to not be hike-a-biking/bushwhacking.  A wonderful pullout with a view of Lake Berryessa to the south was a nice reward before reaching the Helipad. 

We climbed a little more, reaching the flat spot.  With 8.5 miles yet to go across Blue Ridge, we had completed half of the loop.  We ate lunch, sent out some text messages, and pushed OK on the SPOT device. 

Time:  10:16 a.m.

To get up on the ridge, we had to push and shoulder our bikes on a barely distinguishable trail.  Iron stakes marking the trail helped us navigate until the goat path became clearer, though not able to be ridden, at least not within our set of skills.  Finally up top on the backbone of Blue Ridge Trail, we stopped, taking in another grand view. 

We snapped off some photos and set out for Lowery Point/Peak, the 3000+ foot high point of the trail, which was only a little less than 1.5 miles up the ridge.  It took us more than thirty minutes to reach it.  Why?  More bushwhacking, though this time it was through primarily chamise/chaparral.  On occasion, we pedaled, inflicting pain upon ourselves as the scrubby plants thrashed our arms and legs.   I wished I had gaiters on my legs.  Steve, luckily, at least a little, was wearing long socks. 

A few sections here and there, thankfully, cleared out on the rocky faces and we rode with ease, and, too, sometimes having a blast with a technical spot or two.  What a great trail, in those moments, we thought.  From Lowery to Fiske Peak, the trail undulated up and down the ridge, was mostly overgrown, required more hike-a-bike, and frustrated us.  Chamise pollen was floating about everywhere. 

Along the way, we stopped to take a break.  I grabbed some toilet paper.  I noticed that my urine was a little dark.  I told myself that it was not as dark as when I had malaria.  I need to drink more, I thought, and so did.  Steve checked his water supply.  We seemed good.  I drank some more.

Eventually, the trail opened up, meaning we could ride it.  From Fiske Peak going south, local hikers maintain the trail, making for a great mountain biking experience.

“If the entire ridge was like this … “

Despite the maintained trail conditions, I was getting very tired.  Additionally, I was becoming short-of-breath.  Several times I had to stop and walk my bike.  “Why can’t I breathe,” I asked myself. 

Pushing on, we finally got to Fiske Peak:  3.5 miles from Lowery Point, taking us about 1 hour and 45 minutes.  I looked around a few minutes at the view, and then started down.  I wanted to be done.  Steve took a few photos as I looked for the trail off the peak.  Steve noticed where it was, and pointed me in the right direction.

“Only 2.5 miles downhill to go,” I told myself.

Not five minutes into it, we stopped to chat with two hikers on their way up to the peak.  Pleasantries exchanged, we went down.  It was steep with tight switchbacks.  We rode some of them, and then started walking a lot of them. The trail was a little overgrown, to add to the challenge.   Rocks entered into the scene.   Seemingly incredulous, we were hike-a-biking again, over and around and through rocks and steep, washed-out switchbacks. 

I was not doing well.  Still short-of-breath, my muscles began to twitch.  I could not recall ever before feeling my forearm muscles in a state of spasm.  Steve was up head and I was slowing down. 

Thankfully, he stopped to wait for me more than once.  When I told him that I still was having trouble with breathing, he suggested that I walk, and that he will ride ahead, walk back up the trail, get my bike, and walk/ride it back down as I walked.

I did not hesitate to take him up on his offer.  Two back-and-forths later, and after I climbed up and over a 3-4 foot high rocky section, I was done.

“Steve, I need to sit down.”

“Okay, no problem.”

I sat on the trail.  My heart was racing.  Suddenly, I began to excessively sweat.  What is going on, I thought in silence.

I spotted a rock, smooth on its face that had a perfect angle to lie back on. I did so.

After getting both bikes over the rocks, Steve stepped up the trail towards where I was laying.  I had trouble focusing my eyes, my vision slightly blurry.

I began to get scared. 

“Do I push the button?” 

Steve hesitated.  I mentioned again about my breathing troubles and that my heart was racing and that I felt like I could not move, even if I tried.   I was incapacitated.  I was out of water.  Steve had a few swallows left.

“Yeah, maybe so.”

It was my decision to make.  I knew that.  I thought of dehydration and how quickly it can kill you.  I looked at the SPOT device.  I felt that I had greater than a 50/50 chance of not making it out.  I lifted the black rubbery flap marked S.O.S. 

I pushed the red button.

Time:  2:41 p.m.

First thought:  my wife, parents, and siblings are going to be very worried.  I felt terrible knowing that.

Steve stood over me, blocking the sun.  Dehydration was wrecking my body.  I was pissed off, somewhat embarrassed, and more than anything else, scared.

And I could not move.  I was debilitated.

I asked Steve to gather all the bottles and empty any remaining residual fluids into one bottle.  He quickly did it.  Between the bottles and the final drops left in his hydration pack, I got about 3-4 oz of water in me.

My body began to go numb.  Radiating out from my core, my arms and legs went numb, though not entirely numb.  It wasn’t tingles either, and not exactly like when a leg or foot falls asleep, so to speak.  It was a slow, gradual, spreading effect. 

Is this what happens when your body begins to shut down?  Feel less pain?  What is going on?

“Steve, I’m so sorry.  This is not good.  My body is going numb.”

Silence. 

“Please tell [my wife’s name] that I love her, and that I am sorry.  I’m sorry.”  I did not know if this was it, as in … the beginning of the end. 

Numbed body.  Blurred vision.

“Remember, a lot of who we are is in our minds.  Keep a strong mind,” Steve spoke with calmness.

“I might die on a trail in California.” 

Keep a strong mind, I quickly reminded myself.  Breathe.  Relax.

The numbness subsided a little.  Breathe. 

We assessed that the hikers would have to come back down, that they would likely have some extra water (I hoped), that Steve waiting with me was letting valuable time pass by, and that it was time for him to go get water at the creek down below where we started in the morning. 

I tried to move into a shadier spot.  My quads immediately seized up.  I screamed out in pain.  I’ve never had my quads cramp, I said to Steve.  Sitting there on the ground, I shook and rubbed them out.

About thirty-five minutes after I pushed the button. Steve grabbed his bike and headed down the trail. 

Alone, I sat and listened to the forest.  I was not sweating, did not feel cold, though I was a little chilly when the breeze kicked up.  It was a perfect afternoon in the mountains:  warm sunshine, not humid, temperature somewhere in the low 80s.  No fever was present, nor anything like heat exhaustion chills.

Birds sang songs and insects buzzed as leaves fluttered.  I listened for the hikers’ voices.  I tried to rest my mind, stopping it from thinking about my situation:  unable to move, debilitated, less than 1.5 miles from the end of the ride, knowing a creek was down there, and hearing an occasional car pass by on the road that hugged the creek.  Dammit.

I looked at my watch and told myself that if Steve or the hikers don’t arrive by 5:00 p.m., I have to make a move.  What if Steve crashed?  What if the hikers know another way down, or are staying up there for the afternoon? 

Breathe.  Relax.  Do not fall asleep.

Sometime around 4:00 p.m., I heard someone yelling my name.  It was Steve.  I yelled back, “Steeeeeeve.”  I waited and didn’t hear a response.  I yelled again, “Steeeeeeve.”

Maybe ten minutes later, I thought I heard voices.  The hikers are coming, I said aloud to the trees.  Slowly, the voices got closer to me.  I was relieved.

As they approached the 3-4 foot climb over the rocks, I let them know I was laying on the trail, to not be alarmed, that I needed any water they might be able to give me. 

A father and daughter, they were great.   She got out her full bottle and said I could have half.  They stepped over me as I laid on the trail, showing care and concern.

Next thing I know, Steve arrived with two bottles of water for me.  I was so damn happy.  All at once, help arrived and I knew that I’d be okay. 

I reached for the SPOT device to turn it off. 

Time:  4:25 p.m.

The hikers got on their way.  I sat and drank electrolytes.  Steve informed me that he left his bike at bottom and walked/ran back up the trail; in less than an hour, he rode down, filtered water, and ran back up, completing a 3-mile life-saving trip. 

Thump.  Thump. Thump. 

Or …

Thwack.  Thwack.  Thwack. 

The emergency helicopter was within ear shot.  Then we saw it as it passed by us and continued up the canyon.  It turned around and came back through.  We stood in a clearing and waved it off, motioning for it to pass us by and gave a thumbs-up that we were okay.

I felt terrible for having them do that.  Guilt.

We started the walk down.  I could not believe it.  Less than a few hundred feet from where I was laying and unable to move, the trail cleared out and was a smooth ribbon of beautiful trail all the way to the end.  No rocks, it was completely open and would have been fun to ride. 

At the creek side, I sat and filtered water and drank it.  The hikers, whom we passed on the way down, came over.  I joined them, they already offering up on the trail to take me back to my car. 

Time:  Approximately 5:45 p.m.

At my car I sent a text to my wife and family that we were okay and that I will call later.  I became overwhelmed with emotions and tears streamed down my face.

Back down at the creek, Steve and I packed up camp, loaded the car, and went to town to get a hotel room and to eat dinner.

Later on … after showers and phone calls …

We ordered food and sat in the booth waiting for it to come.

“I think I need to lie down.”

“Go ahead,” Steve replied, looking at the floor.

More or less, the next thing I knew, Steve was standing next me, holding me up, saying “Come on, Jim.  Come on.”  I tasted vomit.

I passed out for 3-4 seconds while puking up a little water and a chia seed packet that I ate when I first got back to the car.

Wait staff went into motion and in what seemed to me as being a matter of minutes, the emergency medical team from the local clinic was coming in the emergency exit of the restaurant. 

They asked me questions.  I answered them all.  I was coherent and lucid.  I was not delirious at all. 

They took my vitals.  All seemed okay/within normal range:  heart rate was up in the 80s but came down into the 70s, blood sugar and electrolytes was good. 

“May I get an IV,” I asked.

“Sure.  You wanna do it here,” the guy in charge responded.

“In the booth?”

“We can do it here.”

“Okay, fine with me, but heads up…I pass out when I see needles, get shots, immunizations.” 

One of the guys went and got a 1000 cc IV bag out of the ambulance and came back in to my table.  Steve slid around the booth and sat next to me in case I passed out and fell to my right. 

On the left arm, the needle poked in.  No queasiness followed.  I was good.

While squeezing the fluid into my vein, we had a conversation about mountain biking, different trails around the country, my malaria experience, and yes, it was me who called in the emergency helicopter. 

Strangely, while getting the IV, people were still in the restaurant eating, carrying on with their meals as if the entire scene was not happening.  

IV bag emptied, the emergency technicians packed up and said that if I vomit again, we were to call them immediately and that they then would take me to the hospital.

Middle of the night, from around midnight through 2:00 a.m.:  I get up every 20-30 minutes to urinate.  I was clear every time.  IV. 

I also nibbled at grilled chicken, green salad, and took a bite or two of pizza from time to time. 

Morning came, and I was tired, but wanted to get home.  By 8:30, we were on the road. 

That evening, before the sky was dark, I was holding my wife like never before.

Post-script

The more I thought about it, the more I questioned what really happened to me.  How did I dehydrate in five hours while drinking around 120 oz of electrolytes and water?  (Steve shared some of his water up on the ridge.) 

We got back Sunday evening.  Monday, on the phone with our friend retelling what happened, he—our friend—a former very accomplished mountain bike racer said, after hearing everything, “something’s not right … how did you dehydrate with all that fluid? … might want to get checked out …”  Reminder:  we started out in the morning under cloud cover, temps likely in the low 60s and never going above the low 80s.  I never felt hot, never got chills/goose bumps that are characteristic of heat exhaustion.  I did not have a headache, nor felt any nausea.

Tuesday, on the phone with a dear friend … again … “Go see the doctor.”  My parents insisted the same.

Wednesday morning:  I tell the doctor everything you read here.  His assessment:  sure, I likely was dehydrated, but not severely dehydrated.  He was more concerned about my difficulty with breathing.  He wanted me to see the cardiologist.  Also, I had to get urine and blood tests.

Thursday morning:  Blood drawn and urine sample completed.

Weekend:  Under doctor’s orders, I did not exercise and continuously kept hydrated.  No alcohol of any kind was imbibed.

Monday:  lab results come back.  My AST and ALT (liver enzymes) numbers are high, especially AST, which is more than two times higher than the normal high end range. That means muscle damage.  Also, my CPK is more than 5 times higher than the high side of normal.  Again, muscle damage is evident.

New lab work is ordered for the following week to see if the numbers come down.  Still under strict orders to not exercise, rehydrate, no alcohol, and take it easy.

Thursday:  The cardiologist hears the story, learns of my blood lab results, looks at the electrocardiogram, which depicts a normal healthy, athletic heart and says, “You had rhabdomyolysis.”

What?

“Can you write that down for me?”

Rhabdomyolysis. 

He went on to say that my body was shutting down, that it was telling me to stop moving, and that it was good that I stopped before it got any worse.  He added:  yeah, when Rhabdo sets in, you can reach a point where physically you feel like you are unable to move, and that it seems to happen out of nowhere. 

Two weeks later:  new round of blood tests resulted in everything being back to normal.  Echo cardio gram showed a healthy heart.  I was “me” again, with no indication of residual muscle damage and my liver and kidneys were/are fine. 

I was back on the bike and feeling “normal.”  Laps at the pool felt fine. 

Rhabdomyolysis

If, like me until this happened, you’ve not heard of it, take some time to research and learn more about it.  Thus far, as of this writing, I’ve talked with mountain bikers, personal trainers, hikers, mountaineers, runners … and none of them heard of it. 

As a mountain biker, you want to know what rhabdomyolysis is.  In the Cross Fit world, they call it “Uncle Rhabdo.”  It’s no joke though. 

I am not a doctor.  I only know from the numerous medical journal articles and online health websites that I’ve read since this happened to me. 

This seems certain:  if your urine ever has a hue of orange, strawberry, pale red or slight brown to tea-color, you could be experiencing rhabdomyoylysis, aka rhabdo (rab-dough). 

What’s the concern?  Rhabdo occurs when your muscles are damaged and myoglobin, a protein found in your muscle tissue, enters your blood circulation.  The problem is that your kidneys can’t deal with it, most especially if you are not optimally hydrated, e.g. mountain biking and monitoring/rationing water intake on a remote ride.

The worse that could happen is renal failure.  Your kidneys are overwhelmed with myoglobin, and they fail, and you die if it is not treated. 

However, that is not likely, especially if you get hydrated, which should involve an IV or 10 (!).  Yep, I’ve read accounts of people who experienced rhabdo and were hospitalized for weeks, getting 10s of rounds of IVs.  Also, even if you are fairly well-hydrated, rhabdo can happen, and it will require additional/more fluids. 

Symptoms:  This is the scary part.  There really isn’t anything specific (from what I can tell), other than urine color, and rhabdo can happen out of nowhere.  I can attest to that.  Nevertheless, read this report on rhabdo, if you’d like.  I found it to be the best summary/explanation of rhabdomyolysis that I read while researching:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940504/

Final thoughts:  there is no doubt that the water given to me by the hikers and Steve was instrumental in staving off any more serious conditions.  The IV was clutch too.  It was the beginning of flushing myoglobin out of my kidneys.  I am beyond grateful and thankful to everyone who got me through it.  The restaurant puke was likely caused by taking in too much water and my stomach reacting to it. 

Do different:  it didn’t help that I did this ride with a heavier bike, a fat bike.  All the hike-a-biking and bushwhacking and carrying it over rocks led to over-exertion of my muscles.  That’s on me, not the bike.  Previous trips/rides led me to believe that I’d be fine with a heavier bike.  I likely will think that through a little more for the next trip.  Also, down at Fiske Creek, we passed 2 pools of water.  Next time, when I see water on a remote ride, I will stop, for sure, and drink more, and then filter and fill up. 

Trails 411  

We parked at the Judge Davis Trailhead because free overnight parking is permitted there on Route 20.  We rode from there down to County Road 40 via the Cache Creek Ridge Trail, a gritty, tough double-track that has some steep sections that we hike-a-biked.  It is open to bikes.  You’ll see the bike signs along the way on the trail.  The trail ends at Bear Creek.  You have to cross the creek and go up and over the barbed wire on the bank on the other side, get on the road, and ride 2 miles down the road to get to County Road 40.  There is a crossing farther down the creek bed that would be easier to get up on the road, but you would have to push/carry your bike through the rocks of the creek bed to get to it.  Six of one/half dozen of the other, I guess.

We camped on the other side of the low-water-crossing bridge (a cement slab) that crosses Cache Creek.  Up County Road 40 on the left, after the stone barn on the right, is a nice clearing for camping.  It is on BLM land.  No camping permit required.

Cache Creek Regional Park campground and general store, water and showers:

http://www.yolocounty.org/general-government/general-government-departments/parks/cache-creek-regional-park-campground

The low water crossing/cement slab could be impassable.  BLM office in Ukiah for maps and current info on water levels/creek crossings:

http://www.blm.gov/ca/st/en/fo/ukiah.html

Water availability:  Cache Creek flows year round, and is regulated by the water authority up in Clearlake. 

A CalFire permit is required for operating a camping/cooking stove.  Get it here for free:  http://www.fire.ca.gov/communications/communications_firesafety_camping_campfirepermits

Final word:  the Fiske Peak Loop is not ready for riding.  Do NOT go!  There is other riding in the area, mostly on forest roads, it seems.  If you want to ride Cache Creek Ridge Trail, maybe park a car down at Country Road 40 and do it as a shuttle.  If you want to loop it, you could ride the roads back around, or you could connect via the road, then into the trails at Payne Ranch and work your way back up the ridge and then on to your car.