JOSH MULARELLA, MEDICAL DIRECTOR
Dr Josh is the Medical Director for the Grand to Grand Ultra and Mauna to Mauna Ultra. He is a board-certified emergency medicine physician and the Director of EMS and Prehospital Medicine at Cambridge Health Alliance in Massachusetts. Prior to medical school he was a US Navy field medic for 6 years. After his emergency medicine residency training in Philadelphia he completed a year-long fellowship in wilderness and expedition medicine in Syracuse, NY followed by the Diploma of Tropical Medicine & Hygiene in Liverpool, UK. He is a Fellow of the Academy of Wilderness Medicine (FAWM). Dr Josh has worked at other ultra-marathons in Cambodia, Sri Lanka, Bhutan and the Amazon Jungle of Brazil. He has been involved with G2G since 2013 and M2M since 2017.
Medical Director Introduction
Congratulations on registering for the Grand to Grand Ultra / Mauna to Mauna Ultra! This race will test you mentally and physically unlike anything you have ever attempted before. The Utah desert is quite unforgiving and without the proper preparation and training you can get seriously sick or injured. Hawaii Island has 11 of the world’s 13 climate zones. Temperatures will range from tropical and humid to very cold and almost freezing, with elevations ranging from sea level to over 9,000 ft. in the space of one week. But not to worry, that’s why we are here!
Your Friendly Medical Team
The G2G and M2M medical teams consist of six “medics” who are usually physicians with specialized training in emergency/wilderness/race medicine. On any given year there may also be Physician Assistants, Nurse Practitioners, Paramedics, or Nurses. Once the race has begun there will be one medic assigned to each of the four checkpoints and another one at base camp. The medical director will be mobile out on the course in case any issues arise. Once checkpoints close for the day all medics will make their way back to the medical tent at base camp.
The Medical Tent
The medical tent is where we work AND live during G2G and M2M. We try to keep our home clean (easier said than done) so please keep that in mind when you come visit us. Most of the medical team is at a checkpoint during the day, meaning we have already packed up and left by the time you are having your dehydrated breakfast. Therefore there is no medical care in the morning unless we tell you personally to come in. We have “Hours of Operation” in the evening that end at 8:30 pm since we need to sleep too! There will also be limited hours after the long stage since we are awake all night and need some rest.
Safety and Medical Disqualification
Every year there are runners that manage to finish despite overwhelming pain, illness and utter exhaustion. The line that separates “safe” and “unsafe” is hazy at best as the human body is capable of inspiring feats. We are usually the ones not letting you DNF (Do Not Finish), encouraging you instead to at least go to that next checkpoint. But we also need to make sure you are doing so safely. Therefore if we ask you stupid questions at checkpoints (i.e. when did you last urinate? What is your bib number? What checkpoint are you at? etc)... then answer us. If we tell you to stay at a checkpoint to cool off, hydrate, or eat something... then listen to us. Along those same lines, our main responsibility at checkpoints is to ensure everyone is progressing safely without issue, and we can’t do that if we’re fixing blisters. Therefore you really need to be self-sufficient during the day, then come find us at camp if needed.
I very rarely medically disqualify a runner, but if I do they have almost always already come to that same conclusion. My one rule however, which differs from many other staged ultras, is that if you become so dehydrated as to need intravenous fluids then you are no longer “self-supported” and will be pulled from the race and likely transported to the local hospital for treatment.
The overall theme is that THIS IS A SELF-SUPPORTED RACE. In other words, you should train for this race and run this race as if there was no medical team. There are only six of us in the team and many many more of you… and we have limited hours in the medical tent and are usually too busy at checkpoints for routine issues (i.e. blisters).
It is also important to realize that although we are mostly emergency medicine physicians, we are not working in a hospital (or even an ambulance). We have a limited supply of medications and tape and usually start running out of supplies by the long stage. But what we do have a is a lot of experience, and we’re great listeners. So if you have any issues or concerns at any point, please come find one of us. Good luck!!
Below are brief discussions on various race medicine topics that come up at G2G and M2M. There will be more in depth posts throughout the year in the Checkpoint blog which will be linked below.
Approximately three months before the race starts you will be sent the medical screening letter/form. The purpose of this letter is for you to have an open and honest discussion with yourself and your primary care provider about medical clearance to participate in this race. Should you get a screening EKG? Do you really need to be on that blood pressure medication that can decrease heat tolerance?? Are you crazy for wanting to do this??? But most importantly, this form is NOT so I can disqualify you. It does, however, help the G2G and M2M medical team prepare and mitigate any potential issues that could arise. SO PLEASE BE HONEST!!!
The course at G2G is mostly desert landscape offering little respite from the elements. It is usually very hot during the day, and often quite cold at night. You will be exposed to the sun for several hours per day, and getting sunburned on day one makes the rest of the stages pretty miserable. Make sure to have a hat and use sunscreen liberally.
The high temperatures can be quite debilitating for those coming from cooler climates. And while the mountainous course at G2G won’t give you altitude sickness, you will certainly feel the elevation gains at 5,300 ft to over 8,000 ft (1500 to 2400 m). You should take this into account and incorporate heat/altitude training if possible. A few extra days in Kanab before the race would be especially helpful if your schedule allows.
The Mauna to Mauna Ultra course covers a mix of terrain, including trails through lush rainforest, rugged lava trails, mountain climbs (not technical), open grassland, river crossings, coastal beach trails and sand. The starting line on Day 1 and the finish line on Day 7 are at sea level. In between, you will have climbed the world’s two highest volcanic mountains and traversed from one side of the island to the other. You will climb from sea-level to over 9,000ft (2,700m) and experience the remotest terrain on the island. Since Hawaii Island is the only location on Earth, which possesses 11 of the world’s 13 climate zones, be prepared for extreme changes in weather throughout the week of the race. You will experience most of these climates from wet-tropical (hot and humid) to cool temperate to arid. Please pay attention to the mandatory and recommended gear.
Hydration and Electrolytes
Hydration at G2G is VERY important, especially at night and in the morning since it can be tough to catch up out on the course. During the day make sure you “Drink to Thirst”. Everyone sweats and loses electrolytes at different rates. I cannot, and will not, tell you how many electrolyte tablets you should take. This is something you need to figure out on your own. I strongly suggest you bring your own electrolyte tablets (if you are going to use them) and know how many to take and how often. There will be a limited supply of electrolyte tablets at the checkpoints but the brand and ingredients vary year to year depending on the sponsor.
The desert is breathtakingly beautiful but not without danger. The G2G course is a mix of desert and other terrain including hard packed sand, soft sand, sand dunes, forest trails, red rock climbs, rocky roads and slot canyons. Some stages are littered with cacti, so PLEASE watch where you step. The cactus doesn’t care if you are wearing shoes and gaiters, if you step on one those spines will go right through. And despite our best efforts sometimes the thorns are just too small or embedded to pull out in the medical tent. The main critters to avoid are scorpions and snakes. Usually once a year I’ll see a group of runners standing in a circle… hovering over a scorpion taking photos. They are nocturnal so you will likely only see one at camp. Just leave them alone… stings can be quite painful and can potentially end your race.
Rattlesnakes are more likely to be encountered out on the course while they are warming up in the sun. They want to avoid you just as much as you want to avoid them. If you see one, leave it alone! If you do get bitten on the course then keep moving to the nearest (open) checkpoint. It is very helpful if you can get a photo of the snake from a safe distance. Don’t lie down. Don’t apply any type of tourniquet. Just get to a medic ASAP so we can determine whether you need to be evacuated for antivenom.
Hawaii Island has a unique environment and ecosystem. Given its remoteness, over 90% of the flora and fauna on the island cannot be found anywhere else on Planet Earth. That also means that there are very few predators – no snakes, tarantulas, mountain lions, bears or wolves! In fact, the most dangerous animals that you may encounter would be either mongoose, feral cattle or wild pigs (which were introduced by European traders over 200 years ago). Although rare, the most dangerous thing you could encounter would be a bite from a local centipede – not deadly but it could be painful. Cacti are rare in general and almost never seen on the ground.
A stage race has unique issues that don’t come up at a regular marathon or single stage ultra. Not only do you need to run a long distance with a heavy pack, in the heat, on uneven terrain and sand, but you need to do it several days in a row. Problems like sleep deprivation (there WILL be someone who snores in your tent), chafing from your pack, blisters, dehydration and muscle fatigue will get progressively worse each day. Try to anticipate these problems and plan accordingly. If interested, the medical team will gladly tape up your shoulders and low back (where the pack rubs the most) that first night out at the Grand Canyon after the medical briefing. Please bring your own tape.
Running with a weighted pack on uneven/sandy terrain also alters your gait biomechanics which, over days, if not trained, can lead to musculoskeletal pain/injuries. Which brings us to our next topic…
G2G/M2M can quite literally be a very painful experience. Blisters, chafing, muscle/joint pain, oh my! During the day we recommend acetaminophen/paracetamol (i.e. Tylenol). You can take 1000 mg every 6 hours as needed for pain.
NSAIDs such as ibuprofen and naproxen are another option but they can decrease blood flow to your kidneys. When taken out on the course NSAIDs have been shown to cause kidney damage due to a dangerous combination of dehydration, some muscle breakdown from running (rhabdomyolysis) and certain hormones which peak during strenuous exercise (AVP). Therefore we recommend ONLY taking NSAIDs at the end of the day after eating/hydrating.
The G2G/M2M Facebook Group Page is full of advice on foot care but everyone’s feet are different. I highly recommend the book Fixing Your Feet by John Vonhof which is required reading for the medical team. While it gives excellent advice on treating blisters, it more importantly has several strategies for not getting blisters in the first place. Prevention is key! There is only so much the medical team can do once you get blisters, and every year there are runners who DNF as a result. As mentioned previously, foot care is primarily your responsibility, especially at checkpoints. If you must come to the medical tent for foot care, make sure you wash your feet off outside the tent in the provided bins, and bring your blister kit (required item) with you. We will not treat all of your blisters. Instead we will show you how to do a few and will send you back to your tent to finish the rest.
When you are running at G2G or M2M your body diverts most of the blood supply away from your stomach and diverts it to your legs. This makes it hard to digest food. Sometimes it may even feel like water is just sitting in your stomach sloshing around (called Slosh Stomach). Once you have finished for the day your body will reset back to its normal state and you will start to feel better. Regardless, you may spend a large portion of time feeling nauseous. We recommend bringing medication for nausea to take as needed. I also strongly suggest bringing food that you will actually eat… food that you would want to eat when hung over! This may sound obvious, but every year there are runners who bring meals they have never tried before (and don’t like) or those who grind it up to a fine powder to save weight and can no longer tolerate the taste or texture. And please, for EVERYONE’S sake, wash your hands after going to the bathroom!