After work on Black Friday 2012 I drove to Santa Barbara City College to workout. My brother and I were going to tag-team the Spartan Sprint in Malibu the following Saturday. I’d been losing fitness since my August move to San Luis Obispo removed me from my workout community and routine at CrossFit Pacific Coast (CPC) in Santa Barbara (a poor excuse, I know). I prescribed my own body-weight CrossFit workout to prep myself for the Spartan Sprint. Little did I know my 18 minute dose was about to come with a side effect of 5 days in the hospital.
My workout was 4 rounds for time:
- 400m run
- 20 burpees
The running, I hoped, would help bring back some cardiovascular fitness and the burpees would prime my upper body for climbing and hanging obstacles. The workout certainly challenged me - like workouts at CPC had before - but not extraordinarily so, I thought. I rode my hard-earned endorphin high all the way home, to my leftover Thanksgiving dinner.
Sat. 11/24 Cue Rhabdo Symptoms
The next morning, consciousness came sooner than the courage to leave the comfort of my covers. I awoke to extreme soreness and muscle weakness in my triceps and shoulders. The burpees laughed at me like Nelson at Bart Simpson’s latest blunder. My neck and arms swapped teeth brushing duties that day - my head circling my stationary toothbrush in place of my arms making the toothbrush circle in my mouth. Reaching my head to wash my hair was harder than it should ever be. CrossFit workouts made me sore on the regular; no tingles from my spidey-sense.
I joked to my girlfriend:
After gassing up my car, I started my drive to Valencia where I was meeting my best friend for lunch and attending my 10 year high school reunion. In hindsight, driving 1.5 hours was a poor choice in my condition. Between the trouble I was having trouble raising my arms and the need to shift my manual transmission, it would have been bad news had I encountered anything other than the light traffic that I did.
At lunch with my best friend I made light of how hard lifting food to my mouth was. My tactics improved by evening; I ordered only bottled beers since they required slightly less range of motion than a glass. I caught up with some old friends and enjoyed the reunion before retiring early to my hotel.
Sun. 11/25 Diagnosis Rhabdo
Around 4 a.m. Sunday I woke up achy. “Usually, when I’m sore,” I thought, “it hurts when I move. I’m not moving and I hurt.” My brain-hamster rubbed the sleep out of his eyes and reluctantly started on the wheel until I remembered Crossfit Pacific Coast’s blog about rhabdomyolysis (more affectionately known as rhabdo in the CrossFit community).
Per the NIH - Rhabdomyolysis is the breakdown of muscle fibers resulting in the release of muscle fiber contents (myoglobin) into the bloodstream. Some of these are harmful to the kidney and frequently result in kidney damage.
What we’re talking about here in regular language is tearing enough muscle fiber to overwhelm and ultimately damage your kidneys. Your kidneys are one of your body’s main filtration systems and are responsible for separating waste out into your urine (among some other jobs). Myoglobin will breakdown into substances that will cause blockages in and therefore the possibility of tissue death within your kidney. In other words, you don’t want this happening. Your kidneys are your friends.
Based on the symptoms Traver describes in the blog - dark urine, severe muscle soreness, unintentional weight gain, seizures, etc. - I concluded that I wasn’t suffering from rhabdo. I was just really sore. Harry the hamster and I went back to sleep.
At 9 a.m. I woke up again. When I went to the bathroom, my urine was a dark, tea-like color. Panic set in. I was an hour and a half from home and I was pretty sure I needed to go to the emergency room. I called my girlfriend and maybe, there’s a chance, I might have freaked out, just a little bit, perhaps, depending on how you look at it.
Having never been, the thought of going to the ER terrified me, so I compromised with myself and went to a local walk-in clinic. Inside I told them I thought I had rhabdo. I gathered that the nurse practitioner had not seen or treated rhabdo before. Eventually, they took my blood and sent it to the local hospital for analysis “stat.” They asked me to return to their office in 2-3 hours.
When I returned, the nurse practitioner confirmed rhabdo based on elevated creatine kinase (CK) counts in my blood. According to the hospital lab, my CK count was ~16,000. For perspective, normal CK values are 60-400 units/liter. They hooked me up to an IV and administered 2 liters of saline. Then they asked me to return the following day, Monday, for another round of bloodwork and more fluids as needed. It was an inconvenience for me to book another night at a hotel, miss work and return the next day, but I had dodged a trip to the ER, so it felt like I was getting off easy.
I drove back to my hotel and checked back in to the same room I’d slept in the night before. The drive was sketchy because of my soreness and weakness in my triceps and shoulders. Just turning and shifting my VW had become difficult. Now that a medical professional had diagnosed rhabdo, I did what I probably should have done long ago - I called my parents and asked them to drive 3 hours from Grover Beach so that one of them could drive me and my car back to Goleta the following day.
Mon. 11/26 Take Rhabdo to ER
Return to Doctor’s Office
My parents reached my hotel at 9 a.m. Monday. I was barely out of the shower, but I’m sure Mom was so worried that she’d insisted they leave Grover Beach at 6 a.m. She brought 4 jars of her very own cure-all, Raw Food Betsy’s green juice. If only that could have fixed me!
My parents drove me back to the local walk-in clinic where they drew blood for analysis and administered 2 more liters of saline. The saline would take a couple of hours and we expected to have the results of this second blood test shortly after. We hoped to see the CK count falling.
Before we got those results the doctor asked me to invite my parents in to hear what I thought would be our debriefing. Instead, he told us that while reviewing my case he discovered the hospital lab had updated my results from the day before without informing anybody of the change. My CK count was not 16,000 the previous day, but was instead 160,000! The look on his face communicated before his words that I was (my kidneys were) in more danger than he had thought. He had already called a renal specialist and secured me an appointment 45 minutes later.
Here’s a graph of my CK counts over time:
When the kidney specialist received the results from that day’s blood test and learned the CK count was 165,000 (higher than Sunday), he instructed me to go to the ER. We asked if we could drive back to Santa Barbara and go to the ER there, but he said no, that minutes mattered.
Waiting at ER
This was the first time in my adult life that I’d been to the emergency room. I hope I never have to go back. From the waiting room, there seems to be little urgency. It was extremely frustrating to hear the kidney specialist tell us that minutes mattered and then to wait 2 hours just to get from the waiting room into treatment. We were all worried that my kidneys would be permanently damaged while I waited.
I had heard the term “triage” before, but I don’t think I ever bothered to understand what it meant until then. Per wikipedia, triage is the process of determining the priority of patients’ treatments based on the severity of their condition. That night, to me, it meant that I would have to wait and hope that my kidneys stayed strong while all the people worse off than me were called in for treatment. In honesty, from what I could infer about other people’s conditions I couldn’t disagree with their prioritization - the pregnant woman clutching her stomach and the girl whose foot was run over by a car got in before me. But, I really wanted to get out of the whole situation with two fully functioning kidneys. So I just waited and hoped that the ER would die down and I would get seen.
After two hours I got into the ER and they started me on more IV fluids.
Tue. 11/27 Admitted to Hospital
Sometime in the early hours of Tuesday morning, I was transferred out of the emergency room to a section of the hospital for patients needing less intensive treatment.
From this point on, my hospital stay was a waiting game.
Wed. - Thu. 11/28-11/29 Waiting Out Rhabdo
Being in the hospital sucks; there’s not a lot to entertain yourself with, the food’s not very good and there’s an infinite number of other, more awesome, ways that one could spend their time.
I was on IV fluids constantly. They would help my body flush out all of the junk my muscles had released into my blood. I wheeled my IV pole with me everywhere I went, including the bathroom (a lot). This wouldn’t have been so bad, except they gave me squeakiest, worst-rolling IV pole in the whole place. Damn it.
They monitored my condition and took blood for analysis daily to ensure my condition continued to improve.
On Thursday I was ecstatic when my general doctor suggested I’d be able to leave that day. Unfortunately, morale would only fall when the kidney specialists overruled and kept me another day. He wanted my CK levels to be lower still before I was released.
Friday 11/30/2012 - Released from Rhabdo
By Friday morning I was accustomed to a nurse waking me at 5 a.m. to take my blood. This was the first time it was worth it, though, because when the kidney specialist made his round he said my CK count was approximately 24,000 - low enough for me finally be released!
I texted my girlfriend in Santa Barbara, who was “on call” to pick me up. A few hours later I was released and we beelined to Red Robin for some delectably not-from-a-hospital food.
Despite some drizzle, the outside air between the hospital and the car, and the car and the restaurant reminded me how much I take the outdoors for granted. After 5 days trapped indoors, the air tasted fresher and cleaner than André 3000 and Big Boi could have ever described.
When I left the hospital Friday, my health was no longer in danger. But, man, rhabdo did not stop making my life difficult. Here’s a summary of rhabdo’s aftermath:
- Dozens of medical bills totaling ~$3,400 (after insurance) through February
- No strenuous exercise for one month
- I was refused private health insurance because of my treatment. I had a gap in coverage because of a new job so I had to elect COBRA for $1,200 over 2 months.
- Follow up blood test to make ensure CK counts continued to drop
- This very attractive bruise:
Cool Story. Tell it Again.
My point is: being in the hospital for 5 days and spending thousands of dollars on medical treatment sucks. Rhabdo is real and it can happen to you in just 18 minutes, even if you’re not a hardcore CrossFitter (I’m certainly not).
So, here’s some advice for avoiding rhabdo from someone who has been there:
- Don’t stop CrossFitting/exercising in the first place. I put myself at higher risk for getting rhabdo when I stopped exercising as often and at as high of an intensity. Had I jumped in at a CrossFit gym immediately after my move to San Luis Obispo, I probably would have never given myself rhabdo.
- Ease back into it if you do take a break from CrossFitting/exercising. I made the mistake of pushing myself too far after taking a break fro high-intensity workouts. If you are training for an event like I was, start training early so you have time to ramp up your workouts leading up to the event.
- Beware movements including negatives such as GHD sit-ups, pull-ups and push-ups. In my case, I’m confident that the push-up portion of my burpees, where I lowered my body to the ground, was my rhabdo-inducing poison of choice. Traver explains this in the CPC blog:
Anytime that you have your body weight being supported through a movement by an ever fatiguing muscle through a workout, it’s going to cause damage. We are all able to lower ourselves downward from the pull up bar long after we are unable to pull ourselves back up – it is this physiological ability that will allow us to continue to damage muscle tissue in one direction far more often than in the other. This is why eccentric movements, like a negative (where you lower yourself downward slowly – think of slowly lowering yourself in a ring dip or from the top position in a pull up) are dangerous.
Hydrate. I’m not sure if this is scientifically proven or not, but I figure if it takes 5 days of IV fluids to treat rhabdo, then making sure you are hydrated before, during and after your workout should help your body continue to flush out any harmful junk in your bloodstream.
Should prevention fail and you find yourself with dark colored urine that resembles cola or tea, seek medical attention immediately. Do not pass go. Do not collect $200. No matter how tough of a battleship, fast of a race car or stylish of a top hat you think you are, do not try to tough it out. Permanent kidney damage is not worth the risk.
Thanks Mom, Dad, Em, Joe and Richard for helping me through this one and visiting me in the hospital. Also, thanks CrossFit Pacific Coast for teaching us about rhabdo so that I knew I needed medical attention.
By Marc Asmus