“Just when you’re at your lowest…another wave hits you”

Team Indian Ocean 3100

In April 2011, a 4 man team set out to row 3,100 nautical miles across the Indian Ocean. 75 days, 11 hours and 40minutes after departing from Geraldton, Western Australia in their 29 foot ocean rowing boat named ‘Indian Runner 4’ they completed their epic expedition and arrived in Mauritius.

On completion, Team Indian Ocean 3100 became the first 4 man crew to row completely unsupported across the Indian Ocean. In the event of equipment failure, extreme weather or medical emergency, they would have been entirely on their own with potentially fatal consequence. A simple scientific research programme was set up with the team. Before, during and after the row, they performed physiological and cognitive tests to highlight some of the challenges that the human body and mind encounters when pushed to extremes.

This is a story for anyone who enjoys an eclectic mix of adventure, science and medicine.  It is not a detailed story charting scientific rigor but rather about sharing passion and a reminder that there are still a few last bastions of science and medicine when exploring the human body in the extremes.

 Aims of this Article

(1)          Share an adventure in which the human body and mind is exposed to the extremes

(2)          Illustrate how scientific application to training and nutrition can support performance

(3)          Illustrate a unique situation to perform research

(4)          Provide a case study of medical care far beyond traditional primary and secondary care

Fig 1. Prior to departure

Fig 2. On arrival in Mauritius

Training and Nutrition

This expedition was a race against diminished returns. Now, although deterioration of the body and mind is inevitable when rowing non-stop 3,100 nautical miles, the rate of deterioration will be a key factor as to how efficiently this is achieved. This was the mantra for the nutrition plan and training – delaying the inevitable.

The crew took part in a 10 month training plan leading up to the row. Although impossible to train to row 3,100 miles, you can prepare body and mind. Both the monthly macro-schedule and daily micro-schedule were designed to progressively develop the 3 core pillars of their training: (1) rowing-specific aerobic fitness (2) rowing-specific core abdominal and lower back strength (3) efficient rowing technique. Individual training sessions were combined with fortnightly crew training sessions. Mental preparation was essential and monthly meetings were held to voice concerns, disagreements and perceptions of progress. The aim of this was for crew members to clear any underlying problems now and not in a tiny 29 foot rowing boat!

To maintain optimal performance rowing, the crew’s bodies needed to maintain a positive energy balance. The crew consumed a mix of freeze dried and ‘wet’ foods, along with dry snacks, fresh water (from a desalinator pump) and protein recovery drinks – adding up to over 6,400 calories daily. This diet began one week prior to row to ensure their gastrointestinal system was amenable to the foods.

Fig 3. 24 hour crew training session

Fig 4. Ration packs

Life On-board

The crew rowed as pairs in 2 hour shifts between 0700 and 2200, after which they rowed in 3 hour shifts until 0700 the next morning. During the daytime, when not rowing the crew had to clean and repair kit, cook food (for themselves and the pair rowing), check weather reports or even try a little fishing. At night, they would try and sleep when not rowing. This was not an easy task and the crew never got more than 2 hours continuous sleep once changing out of wet rowing gear, eating food and completing the never-ending ‘odd jobs’, were factored in. It was an endless, sleep-deprived row. Toileting was confined to a bucket that was used behind the rear rower and any waste tipped overboard. Sometimes a simple process, other times not so, especially if the bucket (and rower on it) gets knocked off by ever-present freak waves.

As days turned into weeks, the salt water and irritable ocean swell kept the crew permanently damp and with the relentless sores developing on hands and buttocks from endless rowing shifts, crew moral would wax and wane with the swell. The crew reported days of laughter, tears, arguments and silence. It truly was a journey that stretched them as much mentally as it did physically.

Fig 5. On the oars

Fig 6. Swimming with Minke whale on day 68

Physiological Research

The aim was to monitor changes in simple measures of human physiology. The nature of the tests had to be simple and portable because of the cramped, challenging conditions of the Indian Runner 4 where the tests were performed. The table below provides a summary of the tests, equipment and outcome:

Fig 7. Crew member wasting

Given the huge energy demands that rowing the Indian Ocean required, the results are unsurprising and there were significant declines in body weight, waist size and BMI. Grip strength was significantly affected. However it is unclear if this was related to muscular fatigue or chronic joint and muscle stiffness that developed in their hands (2 crew member received hand physiotherapy months after). A number of tests were also abandoned because of the challenges in measuring whilst in the Indian Ocean. In particular skin-calliper measures showed too much variation to be accurate. Although one crew member managed to perform urinalysis (showing blood++ and probably resulting from the extreme exercise) it was not adhered to by the crew. This was the same for measuring fluid intake and urine output.

With hindsight, if planning expedition-based research, we have to remember that a lab on land is very different from a moving, cramped, dark lab! The tests need to remove as much human error as possible. One way is to use digital equipment that automatically stores the results. Furthermore, a simple test on land is not necessarily a simple test in an extreme environment. Skin calipers, for example, could be replaced with bioelectrical-impedance monitoring to measure body fat.

With Team Indian Ocean 3100, research was self-funded by the team and myself as the Team Research Coordinator and Trainer. With larger financial backing, the opportunity for testing is huge. Future tests could include electrolytes (point of care finger-prick tests); body temperature (remote pill for core temperature, and thermodots for skin), heart rate and oxygen saturation (Saturation probe) and energy expenditure (radiolabelled isotopes).

Cognitive Research

The aim of the cognitive tests was to observe how the crew coped over this extraordinary expedition. To do this, Team Indian Ocean 3100 collaborated with the world leaders in laptop-based neuropsychological assessments, Cambridge Cognition. Using CANTAB technology, consisting of computerised touch-screen tasks, the crew completed CANTAB over a period of 13 weeks, including before and after the event. The aim was to model the time-course of brain performance; in preparation for the event, during the race as fatigue sets in, and also during recovery.

CANTAB technology measuring aspects of brain activity like memory, attention, problem solving and decision-making has been used in pharmaceutical trials worldwide. However, CANTAB has never been used to analyse how the brain copes with long-distance endurance events. With this in mind, Scientist, Julia Noble, from Cambridge Cognition describes how the data collected from Team Indian Ocean 3100 will be used: “We hope that the information we gain will be of use in other sports and endurance events, by enabling us to have unique insight into how the brain reacts under these circumstances. Therefore, hopefully in the future, strategies can be developed to combat any decline in brain function, and improve overall performance.”

The crew managed to complete all the testing and this data is currently being analysed by Cambridge Cognition. Early indications are that the data shows significant deteriorations in cognitive performance. On self-reflection, the crew are not surprised to hear this!

Fig 8. Cognitive testing underway

Medical Issues on Indian Runner 4

Before departure the crew attended an intensive ocean-specific advanced medical course. This covered medical skills from wound and burns management and suturing to administering intra-venous antibiotics and urinary catheterisation. An extensive medical kit was also on-board.

Given the melting-pot of irritants including continuous, repetitive rowing, damp conditions and salt water, the crew developed a number of dermatological conditions. These ranged from simple painful blisters to more excruciating boils that dominated hands, buttocks and the inner thighs. Typically these were managed with padding and anti-inflammatories – although none truly healed during the row since the crew never stopped rowing.

Fig 9. Suffering buttocks

Musculoskeletal problems developed as the race progressed. Simple mechanical back pain troubled the crew. In the severest case, one member (whether rowing or not) had a hyper-flexed spine. This later required physiotherapy after the row.

Claw hand in which the fingers cannot be extended out of a flexed position (e.g. gripping a rowing oar) was a common problem on the boat. This was likely to be combination of joint stiffness and possible ulnar nerve compression. The crew found that before beginning a rowing shift, at least 10 minutes of hand warming and self-administered forced finger extension was required. Again, one crew member required 2 months physiotherapy after the row to regain full function.

With the skin’s physical barrier breaking down, infection was a present risk. One crew member did develop an aggressive peri-anal fungal infection. This was treated effectively with anti-fungal medication and pain-relief drugs. An unpleasant side-effect of pain relief taken that was higher up the WHO analgesic ladder included constipation and sedation. Although the crew persisted through this (although considering a ‘manual finger’ faecal evacuation at one critical stage), it is important to remember that causal effects of medications offered in an expedition environment and the effect on performance. Thankfully no catheterisation took place….

Relevance to Expeditions

In mainstream sport and endurance events we apply scientific rigor and medical attention in pursuit of true optimal performance. I question whether we apply a similar rigor to expeditions and remote pursuits which are to my mind merely an extension of mainstream sports? Expeditioners may not always look like natural athletes but nonetheless if they are looking to break a record or summit a mountain in the most efficient way then why not inject more science and medicine into their preparations and management. A ‘one-size fits all’ approach to performance in the extremes does not work. It must be tailored.

Medicine is as much about knowledge, skill and resources as it is about environment. In the developed world that environment is not necessarily the challenging factor. In the middle of an ocean, at 5000m up a mountain or in the heart of the jungle, is does become the challenging factor. It is clear from previous articles in the Student BMJ too (“The Back of Beyond” Sept 2010 Student BMJ) that this is becoming a sought after challenge.

Ultimately, if we want to continue to pursue new limits and daringly push boundaries when it seems that there is no more to give, let science and medicine step in and act as the catalyst to push us to find that new limit. Personally I find this a very exciting prospect.

Summary

This was the story of Team Indian Ocean 3100 and their experiences of salt, sores and science as they tackled Indian Ocean in a tiny rowing boat. There were 4 aims in writing this. The first was to share a glimpse of the adventure of Team Indian Ocean 3100 as they became the first 4 man crew to row unsupported across the Indian Ocean. The second was to show how even in an unpredictable extreme environment, science and nutrition can be applied to help maximise and maintain physical and mental performance. Thirdly, research doesn’t have to be dull! There are plenty of opportunities to explore human physiology and medical provision in challenging environments for example. If
you can’t find them then consider creating them as I tried, albeit on a small scale. Finally, and perhaps most importantly, this article might have got you thinking outside the box when it comes to medical care and that a career in medicine can open up many exciting adventures beyond the traditional.

Perhaps as we to continue to examine how the human body and mind are pushed to the limits that ‘Expedition Science and Medicine’ may become a new frontier in performance.

Fig 10. On dry land after 75 days

For more information feel free to contact me at uni-liaison@expeditionmedicine.co.k.

Cheers,

Nick

Of interest - Extreme Medicine Conference, London

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