Friday, March 23, 2012

A Public Service Announcement: Endurance Athletes, Air Travel, and DVTs

I've flown internationally probably 100 times in the last 20 years. That may be a bit of an exaggeration, but I've been to around 35 countries, most of which I entered by plane travel, and many of those I've visited multiple times. Regardless of the number, I am not new to flying, and not new to flying half way around the world. But somehow I missed the memo on the risk of deep vein thrombosis (DVT) to me. I'm young (well, sort of), fit, and I guess, a bit naive.

If you want to read about my experience with DVT and then PE, please read the last 2 posts. As far as I know, this was my first experience with either. This was what is considered a provoked incident of DVT. That is, it was brought on by a long flight, and a couple of other factors (birth control, and I'd argue endurance athlete) that seem to increase the risk. It's fairly easy to look at the risk factors and see why it happened to me. I don't know if it's accurate to say that endurance athlete equals an increased risk, but if you do some googling of DVT and runners or endurance athletes and flying, you will quickly come across many different reports, stories, etc. that indicate that it is not uncommon in endurance athletes and a statistic on states that 85% of air thrombosis victims are "athletic, usually endurance type athletes like marathoners."  I have no idea where this data comes form, but arguing the validity of the data isn't really the point of this post.  The point is to raise awareness that this seems not to be an uncommon problem amongst types like us, so to exercise caution when stagnant for long periods of time, like on long flights or long road trips. Kim, an ultrarunner from Ohio sent me the link to her blog where she talks about DVTs in runners and about two running friends with DVTs.  Some other blogs/articles that discuss DVT in athletes can be found here, but again, some quick googling will lead you to any number of related posts (past several words are hyperlinked to some examples).

I am typically a fairly active traveler. Assuming I'm on an airline I fly often, I always sit in an aisle seat so I can get up whenever I want (frequent flyer status often dictates what you're left with, but again, I fly overseas a lot so I generally have some level of elite status and get my preference), I carry on a water bottle, and fill it on the plane so that I can drink often and more than what those little plastic cups hold (also cuts back on use of plastic cups), I often wear compression socks (but not sleeves--try it or think about it and you'll understand why I don't, even though there are any number of websites recommending sleeves for travel, as well), I get up regularly (because I'm drinking a lot) and usually want to stretch my legs. However, I also tend to sleep easily on a plane, so it's not uncommon for me to fall asleep for long naps.

I've also done some really stupid things like when I flew to Nairobi the day after running the Pine to Palm 100.  Getting to Nairobi from Portland involves 2 or 3 flights, 2 of which are going to be 8+ hour flights. Definitely not fun after running a 100 miler, and looking back, probably a bit dangerous. But to date, I never have had another DVT incident that I can remember.

I've received a lot emails from ultra runners who have shared similar stories, great advice, how they dealt with DVT/PE, or tragic stories of friends who died from PE after DVT. Mine is definitely not an isolated incident, so I'd really just like to ask all of my ultra running friends to be careful out there.  Maybe everyone already knows about this seemingly increased risk to endurance athletes, but I didn't.  Had I known, I would have been more cautious. Again, I feel like I'm already fairly cautious, but not because I knew of the risk of DVT, more so because I get uncomfortable sitting still.

I can guarantee that I am going to become the traveler that everyone hates.  That person who is pacing the aisle, and getting up every 10 minutes to fidget. I encourage you all to do the same. I may need to leave a day earlier in the future on trips to destinations where multiple long flights are necessary, like any destination in Africa, either to have a rest day after two long flights, or a scheduled stopover in between long flights, because going forward, the thought of falling asleep for more than 30 minutes scares me. I will be that annoying chick with the alarm that is set to go off every 20 minutes.

And if you find yourself with DVT, there are a lot of scare campaigns out there associated with DVTs and PEs, being on blood thinners, and what you can and can't do with regards to aerobic activity. There is also no good data to support a doctor's advice to tell you to either jump back into it, or avoid activity, and because there is a risk of death associated with PE and no data to support either approach, many doctors seem to take the conservative approach and ask that you avoid activity for up to several weeks/months (that was my first doctor who scared the living bejesus out of me).

There's the issue of physical activity with DVTs and then there's the added fun of being on blood thinners (which is necessary to be active with DVTs). Luckily I'm not a mountain biker, because I definitely wouldn't be comfortable mountain biking on Warfarin, but am comfortable running. Heck, I never fall (obviously not true for anyone who knows me). While I do fall regularly, head trauma is the major concern with falling on thinners, and I can count the number of times on one finger when I've hit my head during a run. If I scrape my leg, I might bleed a little more, but assuming my INR level is where they want it to be (between 2 and 3), I won't bleed to death. There are warnings out there about using blood thinners that go so far to say "don't use toothpicks" and "use an electric razor." I've been assured, that unless I get my INR up to 7 or so, I'm not going to start spurting blood out of a hang nail.  I will have to be diligent about making sure my dosage is correct and that means twice a week visits to the anti-coagulation clinic at this point, although that will become less frequent in the coming week or two.

On a very positive note, I found a doctor I like, and one who works with athletes and has worked with other cases of DVT and athletes.  I'm back running (the past 3 days), and am easing my way back into it and hope to still be able to compete in Italy at Worlds on April 22nd. There's still not a 100% chance that is going to happen, but a few days ago, I would have told you I had about a 2% chance of competing, and now I'm optimistic that it's a possibility.


Olga said...

Thank you for an informative post, and please continue to get better.

Casseday said...

Great post Amy. Definitely informative and thought provoking. Good news about Worlds! Good luck with the training and recovery.

Julie said...

I'm so glad I found your blog and read about DVT. I did not know about the risk and will definitely be very cautious and conscious of it in the future!
I'm glad you are back to running and hope that you continue to improve!

ultrarunnergirl said...

Thanks for highlighting this issue. I am aware of DVT in that my mother has had and is prone to blood clots; but I too assumed that as a relatively young, very fit person I didn't need to worry as long as I got up several times during a flight. And I'm sure a number of us fly to destination races and hop on a return flight soon after finishing.

Forewarned is forearmed.

Anonymous said...

Thanks for this Amy. I am glad you are doing better and continue to hope for your quick recovery. Are you aware if there is any future increased risk of DVT after having it once? I have worn compression socks since I started flying for any races, but know so little about the condition.
Bev Anderson

amy said...

Hi Bev,
There is some data that talks about re-occurrence and I believe the risk is higher in a provoked case immediately after and diminishes, but I'm kind of guessing.

Even though the pain was worse after the flight home from Istanbul, I believe the problem actually started on the way there because I had the same calf pain the first 2 days in Istanbul, and I was wearing compression socks on that flight. They are supposed to help, but don't prevent it.

There are some blood tests that they can do for something called Factor V (and maybe others), that might be a good idea if your mom has a clotting tendency. Clotting issues can be genetic, and it's not a bad idea to get it checked out (in case you haven't).

alligator said...

Hi Amy, Thanks for the informative post! I did not know that endurance training was an added risk factor for DVTs. I'm pretty careful flying (I have varicose veins so consider myself higher risk). I'm definitely one of those annoying chicks who gets up all the time and fidgets! I rarely have an aisle seat so I have to ask everyone else to get up too... I just think they will be safer if they move around a bit also :)
So glad to hear you are back to running!!! I really hope you get to run at World's!!! Please keep us updated!

Meghan said...


All your posts about this have scared the pants off me. I'm SO glad to hear that you're recovering and that you're running again. Gosh, how frightening. My dad lived for much of his life on blood thinners and it wasn't a terrible existence. He wasn't as active as you, but he did things and bled and it wasn't obscene. Take good care.

Devon said...

Amy- Thanks for the very thoughtful information. I have bookmarked it for my upcoming flights to South Africa for races.

My mother has had two DVTs in her life and one PE. She is on blood thinners all the time basically. Turns out she has a genetic predisposition to them....And she passed that along to me. I am pretty freaked out about flying long distances because of it. I would love to be able to afford business class just so I could put my feet up instead of down.
I will definitely try the sleeves instead of socks approach and move a lot. Not like i can sleep on planes anyways!

I hope you are feeling much better soon!

amy said...

What I meant up above was DON'T wear sleeves. At least I've found that they cause your feet to swell up worse than normal, as the blood gets down there but then can't get back up. Just my personal experience with sleeves on the plane. I always go with the socks (when I wear them, which I will from now on, even though they didn't help much in this past instance...).

Maura said...

I am probably a more annoying traveler than you, as I also get the aisle seat and do laps in the aisle frequently! I do wear compression socks on long haul flights (>3 hrs) and have had great success w/these. I once had a flight attendant tell me that I'd consumed more water than 5 other passengers combined! (So???) Glad to know you are on the mend and will be back on the plane soon. Run smart and strong!

RunSueRun said...

Amy, Glad to hear you're getting some runs in! Docs can be so annoyingly conservative; on the other hand, they kind of have to be for liability reasons. Yay! on finding a doc you like. :)

We don't fly nearly as often as you, but often enough. I usually wear compression socks and also take one aspirin an hour or two before boarding. (Obviously you shouldn't do this while on warfarin.) I am even more annoying than you, though, because I like the window seat.

Best wishes,

e said...

Glad that you are doing better and running again. Keeping my fingers crossed that you will participate in the Worlds!

e said...

Sorry - that last comment was from me - Elizabeth Roen

Stephan S said...

It is great to hear you are improving, but sad to know about the pain and stress you went through. As a runner, I really appreciate you sharing so openly and posting info and resources for others. If you have the time and willingness, it would be invaluable to consolidate this for Running Times, Trail Runner, etc.

Tropical John said...

Two words: first class!

Racingtales - Alison Gittelman said...

Thanks for the advice! Thankfully i don't take many long flights, but I assumed that wearing compression socks on my flights to London was enough to keep me safe. Good information.

runnerchick said...

First off congrats on your win in the 100k on Sunday. Not sure you remember me; I'm the woman on Latvian team that talked to you briefly in the locker room after. At first I had confused you with Pam (oops). Anyhow, thanks for posting this. I travel like crazy too. Most of my stuff in within Europe now, but I do cross the pond to the US to race too and do all the things you mentioned above including the compression socks. I'm also on the pill and now concerned even more of the increased DVT risk. I used to often do 2 days of flying between Moscow and Alaska and Kikkan Randall(top US skiier and from Anchorage) got DVT on a trip from Europe back to Alaska. Very scary stuff to say the least. Just curious as to why endurance types are more prone to this. Hope you dont have this again. Good Luck in your races!

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cost per head said...

It is impressive that you have been in many countries and Specially in races because you can see a country in different way that normal person when travel does. From the athlete side of view.