2018. A new year of resolutions and goals. This would be the year where I would take my triathlon goals to the next level and compete in a half ironman. Heck, I was doing pretty well too! I had been consistent in my off season training with Coach Sam and I could feel myself getting stronger. Now, at the beginning of 2018, I was ready to tackle Coach Sam’s legendary brick workouts, 5 hour zone 15 runs, and eternal Trainer Road challenges. DO YOUR WORST SAM! JUST BRING IT!!! Then it happened. On January 3rd 2018 the dreaded H3N2, the virus that this year’s influenza vaccine didn’t target well, entered my life and laid waste to my tri training. As a triathlete I know we are terrified of getting sick. I also know that it’s not the “feeling crappy” that scares you. We all know that “feeling crappy” is part of tri training & competing and you take pride in your ability as an athlete to handle that very pain. Feeling bad is not what you fear. What really scares you is the eternal question that lingers on every athlete’s mind: Should I work out while sick?
As an Emergency Physician, I can impart some advice to you. However, I do have one request from you. My REQUEST is that when you do find yourself sick, I ask that you be ABSOLUTELY HONEST with yourself when employing the tactics I talk about below. I see all types of people in the Emergency Department and not every patient is honest with me. When that happens, my advice is misdirected and will…not…help. So, please, be honest with yourself when evaluating yourself based on my thoughts below.
A little background:
When physicians evaluate patients, we use a thought process reflected in a SOAP note. SOAP is an abbreviation for Subjective, Objective, Assessment, Plan. When we first evaluate a patient, physicians obtain a Subjective history of present illness. This is the patient’s perspective as to how they are feeling and what’s been going on. You tell us your story which may have some numerical values to it (i.e. my temperature was 99 degrees Fahrenheit), but it is mainly your story and your subjective view as to how you are feeling. Next is Objective. This is what the physician sees from a non-judgmental sense in the physical exam and what objective, quantitative findings (i.e. blood pressure) are measured. Next is Assessment. This is where physicians think of all possible causes of the patient’s condition and attempts to narrow down what is really going on based on the subjective and the objective data. Finally the Plan. Now that we’ve pinned down the likely cause of the patient’s symptoms, we have to plan what we are going to do about it. In other words, we’ve created our Assessment (you diagnosis of a viral illness) based on our Subjective (you feel bad) and Objective (you have a 100.5 F fever) findings. Now we attempt to answer your question of whether you should work out along with treatment options.
S: So you’re sick. You wake up in the morning with a sore throat, congestion, and a bit of a headache. Your coach has set up a tough brick workout for you with a 2 hour bike ride and a 30 min run. What do you do? Let’s evaluate your subjective presentation. How do you feel? REMEMBER BE HONEST!!!
Do you feel wiped out?
Are you absolutely fatigued and does even the SLIGHTEST physical activity (walking up the stairs, walking to another room, getting up from a chair) exhaust you?
Do you have a fever?
Do you feel like you’re going to pass out?
If you answered yes to any of these questions...it’s okay to throw in the towel, let your coach know that you’re sick and you can’t work out today. Recover, get better, and fight another day.
But what if you actually feel okay? What if the sore throat and drippy nose is more of an annoyance than anything else? What if you would feel fine if you just didn’t have an annoying, dry cough? If that’s the case you can consider working out…but before you do let’s head to the next step.
O: We are all triathletes, we like numbers, or at least our coaches do (I know Coach Sam does :P), and we have fancy gadgets we wear to test our physical activity. Technically speaking, for our down and dirty objective evaluation, let’s take stock of our vital signs. Now I don’t expect anyone to have a blood pressure machine, but I do expect everyone reading this post to have some sort of heart rate monitor. As you know, heart rate (HR) in exercise physiology lets us know how hard your exerting yourself. Equivalently, in healthcare, your HR lets us know how hard your body is exerting itself when fighting an infection (if you have symptoms of an infection). If you put on your heart rate monitor (while not doing any exertion prior to placement) and its above 100 or ANYWHERE near your aerobic heart rate...I would recommend you skip your workout, let your coach know, and consider seeing a doctor.
But what if your heart rate is at resting levels at rest? Test your HR with minimal exertion. For example, walk up the stairs or around the house. If your heart rate approaches your zone 1 heart rate or goes above a HR of 100, take the day off, rest, hydrate, recover. If I walk into a patient's room and their heart rate is elevated, they have a fever, and I know that they were wheelchaired into the room (no prior exertion), I know their body is working pretty hard to fight the infection. I would consider several more serious diagnoses like sepsis or dehydration. I would have a low threshold of obtaining blood work and at least provide some intravenous fluids (IVF).
Another objective measure is pulse oximetry (SpO2). Some of you may have this and some of you don’t. SpO2 let’s healthcare providers know how much oxygen is in your blood. 100% oxygen saturation is the best and in medicine we usually become concerned if the oxygen saturation drops below 90-92%. If you have this doohicky on your phone or even with your fancy triathlon gadgets, check it out. If your SpO2 is below 94-95% while at rest...take the day off. It may be that your developing a lung infection, like pneumonia, and you should consider seeing your doctor. If it is at or below 90-92% while at rest...DEFINITELY see your doc...it may be a bad pneumonia. If your doohicky says you’re just fine, walk up the stairs or do minimal exertion that SHOULDN’T normally make you tired or even get your heart rate going. If your SpO2 drops, take the day off, and make an appointment with your doctor.
However, if you don’t have this wonderful gadget….here is the poor man’s method. Obtain your respiratory rate (RR). RR is essentially how many times you’re breathing in one minute. One breath is equal to inspiration (breath in) and expiration (breath out). That’s ONE breath. You can count how many breaths you take in 15 seconds and multiply that by 4 and that’s your respiratory rate. Try not to adjust your respiratory rate while doing this and BE HONEST when doing this. Normal RR is 12-20 breaths per minute. If you obtain your respiratory rate while at rest (NO CHEATING) and it is high...No working out. Your body is working hard. If you feel short of breath with this high respiratory rate, go see your doctor. If your RR is normal...hey that’s a good thing, your illness may not be as bad as you think.
Finally, your temperature. Let’s make it simple. If you have a fever, DO NOT WORKOUT. If you don’t, hey that’s a good thing! ☺
Before we move onto to your assessment, let’s quickly recap your subjective and objective components.
Subjectively: if you feel wiped out, if you get absolutely fatigued with minimal activity, if you pass out or are near passing out DO NOT WORKOUT. If you’ve answered “no” to these questions or If you have above the neck symptoms (drippy nose, sore throat, etc.) and answered “no” to the questions in the subjective section, go onto the objective evaluation.
Objective: If your resting HR is above 100 or anywhere near your zone 1 HR WHILE RESTING, DO NOT workout. If your HR reaches your aerobic zone or gets above 100 with minimal exertion, take the day off. If your SpO2 is low at rest, DO NOT WORKOUT. If your SpO2 drops with minimal exertion DO NOT workout. If your RR is high at rest, DO NOT WORKOUT. If you have a fever DO NOT WORKOUT.
So you’ve gotten this far, Subjectively you’re feeling okay. Objectively you seem to quantitatively pass the milestones and don’t have any concerning findings. Now we are entering the “art of medicine” or in your case…”know thyself”
A: As an emergency physician I am trained to think of worst case scenario. The worst case scenario is something called sepsis or septic shock. If you’ve gotten this far through your subjective & objective evaluation, you probably don’t have septic shock. It is likely you have a viral or bacterial infection, either of which will eventually resolve with or without antibiotics (if bacterial). Again, this is only if you are honest with yourself.
P: At this point all of you are asking...WHAT’S THE PLAN?!?!?! Here is my advice and here is where you have to be COMPLETELY HONEST with yourself. If your symptoms are an annoyance, you have a cough that makes your voice sound terrible, your objective evaluation passes the mustard, and you actually feel okay, I would advise you to go workout with caution. If, after 15 minutes, you’re not in it or it becomes incredibly difficult, LISTEN TO YOUR BODY AND STOP. It is also okay to take your workout down a notch if you ABSOLUTELY WANT TO WORKOUT and your Subjective/Objective findings are normal. Just explain it to your coach. Personally, if I have anything above the neck or an annoying cough that doesn’t make me short of breath, I’ll hit the workout. Sometimes the exercise adrenaline will slow that faucet in your nose or clear up your congestion temporarily. Sometimes it may clear up your lungs and suppress your cough. Working out may actually make you may feel a little better. But know that your symptoms will return until you’re completely healed.
Finally, I asked my sports medicine colleague about working out while sick. Here is what she said, “Except mono, we always let anyone participate unless they were febrile. Fever changes your metabolic needs. There were some exceptions - if someone had some URI [upper respiratory tract infection] for weeks and just needed shut down to help them recover.”
All of you reading this blog are phenomenal athletes. It is so impressive to watch each and every one of you compete and train day in and day out. You are stronger than 95% of the patients I see in the ED. You will heal with time and you will recover. I know, I know, it’s the convalescence that sucks. I am just now starting to feel back to my baseline after dealing with this flu for the past 3 weeks. It sucked. I felt like I took 3 steps back after moving 2 steps forward. But here’s the kicker. I have more passion now to attack Coach Sam’s cruel workouts (please be gentle Sam :P) than I did at the beginning of this year. It’s the stresses and the struggle that give us the energy to be better than we were before. You know there’s a word for that. It’s called Evolve.