Episode #354: Man Collapses 50-Meters From The Finish Line (Medical Mystery)

19:44Dr. Austin Baraki:I mean, also no one asked, you know, maybe the dude's just tired. Understandable.

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24:18Dr. Jordan Feigenbaum:10 ,000, built for however you train. This podcast is brought to you by FIGS. Here's a piece of OR history. Before the 1920s, pretty much everything in the operating room was white. The logic was cleanliness. The problem is that surgeons spend hours staring at red tissue under bright lights, and then their red photoreceptors would fatigue. And so every time they would glance away at the white fabric, they would see a blue-green ghost of whatever they were just looking at. An anesthesiologist in New York figured out that if you surround the field with green, the color directly opposite of red, it would cancel out.

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26:10Dr. Austin Baraki:So, uh, all right.

26:11Dr. Jordan Feigenbaum:Well, the patient was given a hundred milligrams of hydrocortisone in the emergency department for suspected pituitary apoplexy, as you kind of alluded to earlier, because they were like, what's this spot? We don't know. Let's give him some steroids. He was transferred to the ICU where he had an EEG done, which was normal. Overnight, this is hospital day one, he was extubated. He was breathing fine on room air. He regained consciousness and he was transferred to the neurology ward. He had no visual signs or symptoms. His pupillaries, a pupillary exam was equal bilaterally. He was reactive to light.

26:46Dr. Jordan Feigenbaum:So no focal deficits there. No nausea, vomiting. who's moving all of his extremities well. So he did get a brain MRI and he had a one centimeter hemorrhage on his left anterior pituitary gland. It's consistent with an adenoma. There are no compressions of his optic chiasm or invasion into the cavernous sinus. That's just a big blood vessel that runs right by the area. He had an endocrine workup done to look at this. Hey, was this pituitary gland functioning normally? So he had an ACTH stimulation test. That was normal. His thyroid studies were normal. His testosterone studies were normal. Growth hormone studies, IGF, all that other stuff, normal.

27:22Dr. Jordan Feigenbaum:Had a cardiac MRI done. No scars, no edema. So ultimately normal. Had a cardiac CT done, however, that showed significant disease of the epicardial coronary arteries. He had a 45 % stenosis in the middle of his left anterior descending and a 90 % stenosis of his right coronary artery. So this is the time, again, where we would pause the podcast. You can re-summarize the patient on your own, maybe hone in on your differential diagnosis. And I'm going to ask Dr. Baraki, what the heck happened to this patient, man?

27:53Dr. Austin Baraki:Yeah. So, I mean, all the things you're telling me, it sounds like I've been awfully on track so far with my thought process, I got to say. So the sudden neurologic syndrome that I was worried about was some form of intracranial bleeding. And that is, in fact, seemingly what happened in his pituitary gland. He bled into that gland. The question is why, which we'll have to still get to and is not entirely something that I would claim as an area of expertise for me, but we'll see what we can do. The hormone workup that was done, that's basically to see, you know, when people have a problem with their pituitary gland, it can lead to dysfunction of all those downstream hormones.

28:28Dr. Austin Baraki:And, you know, the thought of apoplexy and adrenal insufficiency and needing steroids like hydrocortisone came to mind for me. So I'm not surprised that they gave him the 100 milligrams of hydrocortisone. cortisone. I don't know that I would have done that, not because it was dangerous to do, but because he actually did not seemingly show signs of adrenal insufficiency, meaning that you told me his blood pressure was 130 over 80. His sodium was normal. His potassium was normal. His glucose was normal. So those are all the things that would make me think that. And so he was not, clearly not in an adrenal crisis that would need it.

29:02Dr. Austin Baraki:But again, when people are like apparently almost dead, you just do a lot of things if it's at all plausible or reasonable and see if it might help them. So I'm not surprised they gave it to him. I don't know that I would have done the same. I don't think that that necessarily helped him here either. The EEG being normal, so he was not having any seizure activity. Remember from the very beginning, we said a few of the causes of sudden loss of consciousness can be syncope, can be seizure, or a few things. Now, an EEG only looks for seizure while the electrodes are on your brain. It is not going to tell you whether you had a seizure the day before or a couple hours earlier in this situation.

29:35Dr. Austin Baraki:But at least at the time of that EEG. He was not having an active seizure, which is good. And so based on the fact that his cardiopulmonary system was working, he was not having an active seizure. Very reasonable to try to wake the dude up and take the breathing tube out if he was able to participate and manage his own respiratory status, which he did. And glad he regained consciousness. And all that is very, very interesting. It sounds like they continued with the other thing that I said earlier had not yet been evaluated, and that was his coronaries. And so that the cardiac MRI was normal, not terribly surprising.

30:06Dr. Austin Baraki:I didn't have a strong sense that it was going to be abnormal based on everything that's been described so far. And that the coronaries have some coronary disease, I don't know actually how relevant that is to this case. It may end up being a little bit relevant, but at the same time that a 61-year-old guy has some coronary artery disease, it's 40%. Like that's not a shocking amount for someone that age. So that could just be kind of an incidental finding here. It could be unrelated to his original presentation. Again, I had said, you know, from the beginning, the other cardiovascular catastrophe that can lead to these kind of things, aside from neurologic, could be something relating to his heart, like a myocardial infarction or a naortic dissection or things like that, that can also lead to this type of, or certain aspects of this presentation.

30:52Dr. Austin Baraki:But I'm not yet convinced that the coronary findings are as relevant compared with the obvious finding of a hemorrhage into his pituitary gland. If he had just this little area of bleeding in the pituitary gland with no functional consequence on the rest of the gland, it does still seem a little bit disproportionate that he was completely out and unresponsive for as long as he was. That feels disproportionate to me, which is something that's also a bit odd. But I can't say that I have a ton of experience managing patients with pituitary apoplexy. I've seen plenty of folks who have hypopituitarism or various other, you know, areas, sorry, issues in that area.

31:28Dr. Austin Baraki:But like seeing abrupt pituitary apoplexy, not I could, I don't know that I could count on one hand how many cases of that I've seen probably even fewer. So not something I have a ton of experience with. So that's my most glaring abnormality at this point in time. So I'd be curious, for example, is there I'd be searching things like exercise related pituitary apoplexy, could he have had some kind of underlying arteriovenous malformation in the gland that was susceptible to rupturing, to bleeding? Could there be some kind of aneurysm in or around that gland that can bleed? Basically some sort of bleeding predisposition or some anatomic or structural problem in or around that gland that would leave it predisposed to bleeding maybe in the setting of exercise because sometimes bad luck happens while you're exercising.

32:11Dr. Austin Baraki:That's probably about as close as I can get right now.

32:14Dr. Jordan Feigenbaum:Yeah. And in fact, I'm going to give you a deeply unsatisfying answer and you get to experience the same feeling that I did. They don't know. They called this exercise-associated collapse secondary to either potentially a cardiac arrhythmia from previously unknown coronary artery disease during exhaustive exercise or some sort of pituitary hemorrhage. Effectively, if he had a cardiac arrhythmia, it terminated prior to the AED being hooked up, And they actually had a smartwatch, his smartwatch, his cardiac tracing from his smartwatch, which did not show any arrhythmia. So who knows? The patient was discharged from the hospital on hospital day four.

32:57Dr. Jordan Feigenbaum:He underwent a coronary angioplasty with four stints placed in his right coronary artery with 0 % residual stenosis. He later had the adenoma removed from his pituitary gland. And so why this diagnosis of like, look, man, the dude collapsed from exercise. That's what exercise-associated collapse is due to either a cardiac arrhythmia maybe that we couldn't see so we have no real evidence of or maybe this bleed into the brain, which caused no deficits. But it's clearly exercise-associated collapse, which is kind of a – but this diagnosis is of exclusion. He didn't have a cardiac arrest based on the assessment at the scene.

33:34Dr. Jordan Feigenbaum:Plus he had blood pressure, pulses, et cetera. Not acute coronary syndrome based on the EKG and no residual deficits based on the ultrasound that was done. Not heat stroke. He had normal body temperature. It wasn't hyponatremia or electrolyte disorder. They tested that in the field and when he got into the hospital. It's not an endocrine thing because he had normal sort of markers there and not a stroke or like neurological issue that we could otherwise identify because he had the normal CT, normal MRI. and so to me this was deeply unsatisfying it's like look this maybe the dude was just tired i don't know man it just went down had some weird abnormalities that looked strange because of exercise but ultimately like yeah i don't know was it arrhythmia that like nobody's nobody picked up was it this small bleed into his uh pituitary gland and was that even is that even recent we don't know you know could have been yeah i my my sense yeah i'm i'm questioning a lot of things

34:32Dr. Austin Baraki:about this report. I think that presenting something without a definitive diagnosis, I'm totally fine with because I think that, you know, people out there who are listening to these kind of things or watching medical mystery TV shows, they probably get an inaccurate sense of how often you come to a clear definitive answer in these types of mystery cases or symptoms that people have. It's way more often that we end up ruling out a bunch of things but not making a definitive diagnosis. I wish it was not that way, but that is actually more reflective of reality. Sometimes we do come to a definitive diagnosis, but not always as often as we'd like.

35:06Dr. Austin Baraki:In this situation, I am way more in favor of a neurologic cause than a cardiac cause, particularly if he was wearing a watch that was tracking his rhythm. He had structurally normal heart, normal baseline EKG. I'm not actually sure he needed any of those stents that were placed in his coronaries after this. That's a whole separate discussion. but the apparent objective finding of a bleed into his pituitary gland is the most striking abnormality here and that's where I would put most of my cards here. Additionally, you can actually differentiate a little bit like super fresh blood from old blood on a CT scan of the brain.

35:44Dr. Austin Baraki:So the timing of it is something that actually a radiologist should be able to kind of help you differentiate. So it's interesting and of course we don't know whether he was ever able to give any history once he woke up of like, oh, yeah, I had this splitting headache right before I, you know, there's something like that, or I had like crushing chest pain, which again, wouldn't fit with what we saw. So I'm questioning the diagnostic acumen of those who claim to be completely clueless about this. I'm more strongly leaning in the direction of a neurologic issue than cardiovascular, as well as questioning a few other things here.

36:14Dr. Jordan Feigenbaum:But yeah, interesting case.

36:15Dr. Austin Baraki:Glad he did okay.

36:17Dr. Jordan Feigenbaum:Yeah, he got back to exercise and whatever. You know, the case report to me was a little strange because not once was there any sort of subjective, you know, history taken from the patient. Like, hey, dude, how did you feel? Yeah. You know, or like, do you have any medical conditions? Right. You know, like literally any of that. And then further, you know, the discussion point was more of just like, here's how our team operates in a, you know, in a setting like this. And so, yeah, I had two pearls. You stole the first pearl, which is totally fine. Like I would say that more times than not, a very clear diagnosis is not something that – stamp it, boom, we got it.

36:55Dr. Jordan Feigenbaum:It's this one weird trick like that's – yeah, it's generally a little more complicated than that. And then the second pearl, I wanted to talk about exercise-associated collapse because if you're a personal trainer, your strength coach, you're working with people in the field, this may happen. And I think it's important to kind of have your – a sense of like what could possibly be going on and also just kind of know like what to do rather than being like, yeah, it's fine. Like nobody's – this is never going to happen. So we'll talk about exercise-associated collapse. Now, there is a sort of central clearinghouse called the National Center for Catastrophic Sport Injury Research, the NCCSIR.

37:32Dr. Jordan Feigenbaum:That's in the United States. They have tracked and analyzed catastrophic injury amongst both high school and collegiate athletes for the last 40 years. Now, they categorize athletic injury as either direct from like trauma or indirect and that's exertional. So collapse, exercise-associated collapse is a specific type of injury that can be defined as a failure of a physiological system. So cardiovascular, pulmonary, nervous or musculoskeletal system, for example, in the sporting environment. And whereas where collapse means that the athlete is unable to continue participating and unable to remove themselves under their own power from the race course or the field due to a failure in one of these physiological systems.

38:12Dr. Jordan Feigenbaum:As far as exertional type exercise associated collapse, of the 86 events recorded from July 21st, 2021 to July of 2022, 86 percent were documented in high school students and over half of them were fatal. 56 % were fatal. Most of them occurred during practice and the thought is that heat-related illness is the biggest cause there. For trauma, this is like a post-traumatic collapse after tackling in football or like ice hockey, lacrosse, gymnastics, even cheerleading, for example. It's had a few case reports in the past year. You might not necessarily see a loss of consciousness when people collapse.

38:56Dr. Jordan Feigenbaum:So for example, if it's a musculoskeletal injury, a person may be – remain conscious. but still collapse or a person with ECAS, that sickle cell trait-related collapse. They didn't lose consciousness but they still collapsed. But it could be that the person is unconscious if they have something neurological like a stroke or if they have an arrhythmia, the person can be unconscious like our patient was. The most common medical condition that leads to this sort of exercise-associated collapse in the endurance sporting setting is called exercise-associated postural hypotension, E-A-P-H. Basically means you're lightheaded after your exercise due to low blood pressure.

39:33Dr. Jordan Feigenbaum:These folks are generally described as weak, wobbly, and dizzy. And this is most common when people collapse after crossing the finish line. Usually they cross the finish line. They stop running. And the thought here is that they lose the skeletal pump, or as our friends in the South Pacific say, the skeletal pump, which was moving blood from the lower limbs back to the heart. And so you get pooling of the blood in the lower extremities, not enough blood flow out of the heart to the brain and the person gets lightheaded or goes down. For example, this is the leading cause of evaluation in the finish line medical tent.

40:07Dr. Jordan Feigenbaum:And generally the treatment is put your feet up. Yeah, cool. You can bolus yourself by raising your legs. That's a well-known concept in the hospital setting. Keep running. Yes. So in a study of over 150 ,000 runners participating in half and full marathon races over an eight period, the overall incidence of that was about 1.5 percent, which is a significant amount of individuals. Risk factors for this include a longer race, running at a slower speed, high temperature and humidity, and then running uphill if the course is significantly uphill. Those are all increased the risk of having this sort of exercise-associated postural hypotension.

40:46Dr. Jordan Feigenbaum:Now, you kind of spelled this out beautifully during this case, but like the differential for exercise-associated collapse includes things like a sudden cardiac arrest. So famously a person on a football field, basketball court or whatever just goes down in the middle. It could be due to a sudden cardiac arrest. The heart stops. It could be due to exertional heat stroke. It could be due to exercise-associated hyponatremia, which basically means your sodium levels are too low, less than 130 millimoles per liter. What people don't understand really about this is that the most common cause in sport for this is the combination of drinking what are called hypotonic fluids.

41:29Dr. Jordan Feigenbaum:So like free water, for example, or fluids that don't have enough salt in them, plus excessive losses for like a long duration event, like four hours, for example. So people will just be drinking water. They're like, I don't need anything or whatever. They're kind of over hydrating themselves compared to the amount of sodium that they're losing in the sweat. But even sports drinks like the modern Gatorade, for example, doesn't really have enough sodium. It has more sodium than water, for example. But yeah, overdrinking is a big problem here.

41:59Dr. Austin Baraki:Yep. I describe it to folks as effectively waterlogging themselves, just diluting their blood sodium levels down too far while they're also losing it in a sense. This is something that would not – even though all collapse by definition is kind of sudden, there's not like a slow motion collapse. this is something that takes a little while to develop whereas some of those other causes that you mentioned like sudden cardiac arrest from a structural heart issue or from an arrhythmia somebody has a seizure or you know generally a bleed or a stroke in the brain things like that those tend to be much more abrupt in nature whereas the sodium you know you could probably if you had a some kind of real-time sodium monitor they'd probably start out their race normal and just gradually trend down and down and down and down and down until finally their system is not able to compensate anymore.

42:43Dr. Jordan Feigenbaum:Yeah. A couple other potential items on your differential include anaphylaxis. So that's possible. A severe asthma exacerbation, that can happen. Although, again, you'd have some pulmonary findings and likely witness a little prodrome to that. Trauma can obviously happen if somebody has a severe concussion or cervical injury, something like that. Seizure, as you've discussed a number of times. And also hypoglycemia, like an insulin shock, particularly in individuals with poorly controlled diabetes, those using insulin, stuff like that. There's a few case reports of bodybuilders having that in the locker room, doing a little self-administration of insulin, for example, which zero out of 10 would generally not.

43:24Dr. Austin Baraki:Yeah, I would not be playing with that stuff. But, you know, caution advised if you choose to do so.

43:30Dr. Jordan Feigenbaum:I had a friend. Yeah, they were like, hey, I've been taking two IUs of insulin post-workout with 100 grams of carbs. try to gain some more muscle mass. I'm like, that seems silly to me. And they said, yeah, well, a couple of times I accidentally gave myself 20 IUs. And I was like, I'm glad you're still with us.

43:48Dr. Austin Baraki:Yeah, when you're an insulin sensitive person, that is not an insignificant amount. Two is kind of not a huge deal.

43:55Dr. Jordan Feigenbaum:Homeopathic dose of insulin.

43:56Dr. Austin Baraki:Yeah, I give doses far higher than that to folks with actual diabetes, but they actually have diabetes. That's not the same for somebody who's not only baseline insulin sensitive, but just exercised. So they're extra insulin sensitive.

44:08Dr. Jordan Feigenbaum:Totally. Yeah. Yeah. So as far as what to do about this, right? Like if you're a personal trainer, you're a strength coach, you're working with people in the field or athletic trainer, PT, whatever, it is not your job to do a differential diagnosis. And in fact, these are – this is an emergent sort of thing, particularly because if one of these very severe things is happening, like a sudden cardiac arrest, heat stroke or whatever, you have to get the person to the correct level of care, which in general is a hospital. So things that you should have on board. One, you should have a good history on the individual as far as like what medications do they take?

44:42Dr. Jordan Feigenbaum:What medical conditions do they have? If you're working with somebody one-on-one, that's a reasonable ask. Should also be CPR, AED certified. Have your BLS certification. Would recommend all adults kind of have that. It's not too big of an ask for most folks to get. Be able to activate EMS, either directing somebody else to call 911 or you call 911. Be familiar with that. And stay in call during this. Now, there were – I remember my days as a personal trainer. There were less than a handful of times where somebody went down, right? But people freak out. And it would have been nice if I had my medical training prior to those events because I would have been more adept at like, OK, let's activate EMS.

45:21Dr. Jordan Feigenbaum:Let's get the AED, whatever. But I can understand that would be absolutely terrifying. Especially if you're like, well, I don't know. Does this patient – does my client – do they have diabetes? Do they have some sort of other medical condition? You know, they have seizure, a seizure disorder, for example. So, yeah, I think, you know, I'm not asking anybody out there to diagnose an individual on the spot who had exercise associated collapse. But knowing that it does run the gamut from like pretty benign, self-limited, you know, type stuff all the way to like get your butt to a hospital now via ambulance.

45:56Dr. Jordan Feigenbaum:Yeah. I think that's helpful to know.

45:58Dr. Austin Baraki:Agree. I think that my strongest point to advise based on what you described is the AED and BLS training for folks. I think you can very straightforwardly save someone's life, and AEDs are not difficult to use. They're designed to be very not difficult to use. Yeah. And medicine isn't always pretty. No, nor is it easy. Sometimes messy. You don't always get a diagnosis. But at least, you know, we get to I enjoy the privilege not only to do this, but also, you know, experiences that let me practice like this one, for example, you know, execute the thought process before it actually happens and kind of refine and refresh things that I've thought about repeatedly over time and get better and faster and more adept at it.

46:43Dr. Austin Baraki:You know, only in time for AI to take over my job. But that's right.

46:47Dr. Jordan Feigenbaum:That is what it is. All right. Well, that is a wrap here on the Barbell Medicine Podcast Mystery Case Edition. Shout out to Dr. Baraki for sharing his clinical expertise with us. Before you guys go in here, please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you all the latest nuance in health and fitness. From everyone here at Barbell Medicine, I'm Dr. Jordan Weigenbaum. We'll catch you next week and every week right here on the Barbell Medicine Podcast.