







Road running is like a peanut butter and jelly sandwich. There’s nothing particularly thrilling or unexpected. But it’s a comfort food, and sometimes it just hits the spot.
Lately I’ve been stretching myself athletically in ways I haven’t since way back when I was a kid. It’s been exciting, learning new sports like swimming and mountain biking, getting back into skiing, running my first 50 miler at Bull Run.
But it’s all been a very humbling experience. I’ve had to learn how to get passed. How to half-drown and gasp in the pool as I try to thrash across 25 meters. How to miserably watch all the perky ponytails go by as I sit barfy and queasy in a chair mid-Bull Run. Aaron likes to mention how I’m the only person he’s ever seen get off a bike to go down a hill.
Ultra running has kind of bludgeoned a part of my self-image.  Since I moved to DC in 2008 I’ve raced the road marathon distance seven times, each time within a mere four-minute window, between 2:55 – 2:59, always managing to slip under the three hour barrier. I’ve run injured, I’ve run sick, I’ve had stomach problems, I’ve pooped in the woods midway, I’ve been overtrained, undertrained – but I can always churn it out over those short distances.  I’m similarly consistent at the 5k (all under 18min), 8k (under 30min) and 10k (under 38min) distances.
I remember chatting with Ragan after one of the Women’s Half Marathons, and she admitted she was hoping I’d blow up in the second half. I recall being somewhat stunned. Me? Blow up?  I’m 4-for-4 at the Women’s Half Marathon from 2009-2013.  And then I realized that Ragan knew me not from road racing, but from the ultra races. Of course she figured I’d blow.
Because when I venture past the 26 mile mark, my race turns into a game of roulette. At one end, I could have smooth sailing like at Highland Sky last year. But problems that I can tough out over short distances take a much larger compounding toll over longer distances, and at the other end I could have Holiday Lake, Willis River, and Bull Run.
It’s eaten at my heart that I can’t be a rock-hard competitor at the ultra distances, that I can’t count on giving an expected showing.  Maybe others learned this a long time ago (I think Aaron’s way ahead of me on this one), but I’m just beginning to settle on the idea that it’s somewhat pointless to compete with intention at all at ultra distances — you just have to accept however the roulette happens to spin that day.  It’s not in my nature, I *love* competitive sports, and turning down that nozzle is hard.  But I’m beginning to accept that you can’t approach an ultra the same way you can approach a shorter race, with expectations.  You can’t will performance.  At least not at my low level of ultra experience.
So after a six month road running drought, there was something cathartic about getting to churn out a good old fashioned road marathon, to know exactly what’s gonna hit me and how to take the punches, to win and take the prize.  And even if it’s roasting hot, and even if my foot hurts, and even if my stomach sours and I have to scratch some leaves in the middle, I know exactly how to gut it out.
~ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ~ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ~ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ~
‘So, are you planning to run the Boston Marathon next year?’ Aaron asked as we bumped along in our Jeep through eastern West Virginia.
‘Yeah, I gotta. Â That’s 2015.’ Â (I’m on a three-year Boston plan: 2006, 2009, 2012….)
‘So, what are you going to run as a qualifier?’
‘Oh, crap!’ Â I responded, and nodded off again. Â I had woken up at 4am that day, flown from Managua, Nicaragua, to Houston to DCA, gotten home that evening for just long enough to throw all my dirty clothes in a trash bag, and headed off to Canaan, WV with our cat Leda.
The problem with Boston registration occurring in September is that there are basically no marathons in the DC area in the months leading up to it to run as a qualifier (except an indoor marathon that’s like 200+ laps in Arlington in July).  If you haven’t run a fall or spring marathon, you’re pretty much screwed.  But we had run the Delaware Marathon last year (the last time I needed a last-minute BQ — although I later changed my mind and opted for Bull Run instead), and it was a pretty nice and convenient little race.  The $500 purse I won for 2nd place last year didn’t hurt either.
But we had big plans for the weekend in Canaan, so no way were we going to sacrifice those to taper. After a Saturday running through the Sodds, we upped the ante on Sunday and hopped onto some rented mountain bikes and headed into the Canaan wilds.  Now, a year ago you would never have found me on a bike or in a pool.  I had long declared a bicycle to be the Vehicle of Death.  In a pool I behaved much like a drowning cat in water.  Have you seen those Youtubes of them dropping the lion cubs in the moat for their ‘swim test’?  Yeah, that would be me.  I considered triathletes to be a separate species.  But Aaron is a sneeeeeaky bear, and he has been chipping away at these steadfast positions.  He got a big boost last fall when my fibroma was diagnosed and I had to find other ways to stay off my feet.
It was only my third time biking as an adult.  Aaron had told me that we were going to be biking on a ‘gravel road’.  I reminded him of that description when I found myself (a) biking hub-deep through lake-puddles, (b) getting flung over my handlebars when my bike sunk hub-deep into mud, (c) navigating steep rock chutes, and (d) biking up 1800 ft over a 4-mile climb.  But I LOVED it.  My butt bits were in a pretty sorry state after three hours of hard bouncing.  But my fibroma has sadly impaired my ability to run rocks, so it was a thrill to get to go mad-adventuring again.  In some ways, mountain biking reminds me of horse riding – well, a bit more like bronco riding, but I’ll take what I can get.
On Saturday we kept up tradition by running the Race for the Cure with my mom and Aaron’s mom.  R4C is my mom’s one big race of the year, and she rocked it once again in 41 minutes.  Aaron’s mom won her age group in ~29 minutes.  After Mother’s Day brunch with the moms at Old Ebbitt Grill, we skeetered off to Wilmington.  After our bulletproof-glass-registration-desk-nestled-between-two-strip-clubs disaster of a hotel last year, we treated ourselves to the Westin this year.  Best decision ever.
My foot was still hurting (I’ve now developed a second fibroma, about a cm towards the heel from the first one on the same foot), so there was a lot of uncertainty about how my race would go.  I opted to wear my Montrails to try to give the fibroma maximum protection from the pavement.  Aaron wasn’t sure how he was going to run either. I was still feeling the effects of our marathon bike adventure body wide.  So we just ran together, and let two other women go a ways ahead at the start.
I’ve come to really appreciate the charms of the mid-sized marathon. Â There were about 500 people who finished the marathon, and about 3,000 total participants in the marathon-relay, half marathon, and marathon combined. Â The logistics are beautifully easy. Â It’s also fun to be able to compete for the prize purse, which at Delaware is pretty healthy given the relative strength of the competition.
I’ve also come to enjoy the mellowness of the small-city marathons.  When it’s not wall-to-wall fans, it’s easier to focus on the few energetic folks — the guy strumming Bare Naked Ladies on his guitar on the King St hill, the band near mile 16, the kid with the realistic sign ‘Go Stranger, Go’.  The course had good variety, starting along the river and winding up into the neighborhoods.  And, critically for any marathon held in mid-May, a good part of the course was covered by the shade of trees.  Despite Delaware’s reputation for ultimate flatness, the Delaware Marathon does have a significant 1-mile hill (for a road marathon) that they make us run twice (the course is two loops).
The woman in second place had dropped off the pace and I passed her on the first big hill (mile 6ish).  The stretch after the hill was a long straight boulevard and I could see the first place woman up ahead.  Aaron noticed that I was starting to reel her in way too quickly, and reminded me to cool it, illustrating reason #1 why it’s so much better running with Aaron.
After I took two gels my stomach turned and I desperately had to poop.  I was able to hang on for a while.  But when we hit the big down hill, I started to scope out escape plans.  There were some poop-friendly woods off to our right that looked awfully inviting.  But they were rife with poison ivy.  I had to poop, but I didn’t have to poop bad enough to plunge into a grove of poison ivy.  Finally I saw a little dirt trail that skeetered into the woods and I made the quick call.  I’m terribly proud of how efficiently I was able to drop trou and eliminate.  I really think I set a PPR (personal poop record).  Definitely a time to draw on one’s trail skills.
The major trade-off of the local marathon compared to enterprises like Boston is the small hiccups in race organization.  Overall, the Delaware Marathon was extremely well organized.  There were mainly just minor omissions — gels weren’t delivered at the aid stations they were expected at, it was a challenge to figure out which cups were water versus Gatorade at the aid stations, etc.  I started to get dizzy when the promised mile 14 gel hand-out didn’t materialize.  But Aaron handed me one of his own (reason #2 why it’s so much better running with Aaron).
But there was one major snafu: the volunteer who was supposed to direct runners at a key traffic circle around the halfway point was missing, and runners were mistaking the circle for the turnaround and doubling back too early.  Aaron of course knew the course and kept me headed in the right direction (reason #3 why it’s so much better running with Aaron).
At the turnaround around mile ~15 there was a chance to see where the lead women stacked up. Â I was about 3 minuted behind the lead woman, and about 3 minutes ahead of the 3rd place woman. Â An amazing Kenyan guy was running away with the men’s race. Â We steered as many confused runners the correct way around the traffic circle and towards the real turnaround. Â But some guys had turned early and the RD ended up re-calculating their times to make up for the lost 0.7 miles.
Around mile 16 you pass by the start/finish/relay transition area by the river that is teeming with people and you can’t help but pick up your pace amid all the cheers.  But you turn the corner and suddenly it goes blank quiet, you’re running under a grimy underpass with potholes everywhere, and it dawns on you that you have an entire second loop to go.  It’s around mile 16.5, and you can’t help but start to fantasize about quitting running for the rest of your life.
‘Did you see that?’ Â Aaron asked me.
I was too busy wallowing in my lowliness to see much beyond my feet. Â ‘See what?’
‘The lead woman was sitting on the curb.’
I lifted my chin up. Â ‘Seriously??’
‘Yeah, she was there with the pace bike.’
‘Sweet!’  (reason #4 why it’s so much better running with Aaron)
At that point, the race was only mine to loose, and we ran a spirited but conservative second loop.  The day was heating up, I wasn’t sure whether I was well-trained or not, and the woman was unlikely to catch me unless I blew up.  I still was having some stomach issues, especially after consuming any gels, so I decided just to run smart and controlled.  In the end was pretty darn nice to be able to finish a marathon not feeling absolutely miserable.
As Aaron and I were entering our final mile of the 2014 Delaware Marathon, it occurred to him that they better have a tape waiting for me to break at the finish line.  Aaron has been listening to me grumble for a while about how with all the races I’ve won over my 20 years of competitive running, including a couple marathons, I have never had that little thrill of breaking the tape at the finish line.  I know it’s trivial, but I’ve had it on my bucket list for a while.
We crept in just under 3 hours in 2:59.  I’ve run my last six marathons within a four minute window of 2:55-2:59.  It’s nice that my natural pace seems to be just under the critical 3-hour threshold– just pure lucky I suppose, as if the race was a mile longer I’d be over.
I chatted with the RD and a news reporter after the race, who ended up writing a nice little bit that included Aaron’s role keeping my race in check.  The interview got cut short by my desperate need to poop, and for about an hour or so my stomach was pretty sick.  But it was so much better being sick at the Westin compared to last year’s grungy little hotel where the maids were practically peeling me off the floor at check-out time.  I don’t take Immodium during races, but maybe I should(?)  My stomach always spasms.
As the first-place female marathon winner I won $1,000 in prize money, as well as a lifetime free entry to the event.  I decided to put the winnings into the Martha Health Fund towards massages and medical care for my foot.  I’ve made an appointment to see a new foot specialist in Baltimore in June, as I’m really disappointed that the problem seems to be proliferating.  But if my running career gets cut short, at least I had my little moment of breaking the tape.
The Bethesda-Chevy Chase High School track team filed off the cheese bus into an overcast Saturday morning at Middleburg High School. The heat wave that had singed DC for much of early May had finally lifted, and the 70-degree temperatures felt chilly enough to keep our vinyl blue-and-gold track suits on.
‘Damn!’ David exclaimed as he stepped off the bus, removing his headphones and pointing at a large dome structure ahead. ‘What the hell is that?’
‘It’s a silo,’ Alpha said tersely. Â ‘Welcome to Middleburg.’
‘Say wh-at?’
Alpha did not respond. A senior, this was Alpha’s final 2A West Regional Track & Field Championships, and she could not be bothered with David’s unfamiliarity with rural Maryland.
Maduba lifted her beaded braids from her eyes as she scampered off the bus. ‘Man, looka all dem white kids!’ Maduba could get away with saying things like that because (a) she was from South Africa, (b) she had a black mom and white dad, and (c) she could run 400m in 60 seconds.  Maduba was also known for getting away with eating three hotdogs before running her 400m race and still outkicking the field.
We ambled to the track as a disorderly herd that bothered Alpha far more than our coach, Mike Flemming. Coach Flemming had been a star runner for Nebraska some forty years ago, and his coaching style was defined by a strong emphasis on calisthenics. In the next months, my parents would stage a coup that would remove Mr Flemming as our fall cross-country coach after twenty-odd years on the job. They had a legitimate complaint, as the girls cross country team didn’t even have the five runners required to field an official team. But little old Flemming had such cute twinkly blue eyes I still felt bad.
There was a lot of commotion on the track, and enough banners and streamers to look  like a state fair.  I watched a giant shot putter, bursting through his ill-fitting singlet, dip into a deep squat and hurl a metal ball across the field, much farther than anyone on our team could throw.  Someone was speaking over the loudspeaker, but there was too much background noise to make it out.
The metal bleachers were cold and reeked of IcyHot. Assistant Coach Smart handed out the order of events. Thankfully the mile came early so I didn’t have to wait around all day on edge.
Dave bounded from behind and grabbed me by the shoulders gleefully. ‘It’s do-or-die today! You ready, Min?’
‘I think I would rather just die.’
‘M-in!’
‘Regionals is the worst.’ I sighed. ‘There’s no glory, it’s just something you have to get through so you can go on to States.’
‘Hey, not all of us are guaranteed to go on.’
‘I know, I know. Last year qualifying was super exciting.’
‘Martha. Go warm up.’ Coach Smart was in full clipboard/cap/perky ponytail organization mode.
‘Already?’
‘One hour til gun.’
‘I don’t need an hour to warm up,’ I protested.
‘You’re always whining. Go.’
I unzipped the insides of my blue track pants with gold and white blazes on the sides, and reluctantly extricated myself from my giant grey hoodie. Underneath I had a mesh white singlet with scratchy blue and gold trim and B-CC in block letters, and the flimsiest petals of shorts, cut high on the leg and the trim coming undone at the bottom. We had no evidence, but I’d have bet all my lunch money that our uniforms dated back to the 70s.
I warmed up alone in the parking lot. The last time I had been to Middleburg was the regional cross country meet last November. Cross country was so much better than track. I missed the course walks, where we had 3.1 miles to stroll the course as a team, ostensibly learning where it went so we wouldn’t get lost in the race. But we goofed off so much I could never recall where the course actually followed, and my mother could always tell when I got that deer-in-the-headlights look when I came around the turn with absolutely no clue where I was supposed to run.
I trotted around the high school, right by the spot where seven months ago Tripp O’Connell had recounted his traumatic regional cross country race. Tripp had arrived at the race wearing spandex shorts under his uniform. But the power tripping race official had ruled that every team member’s uniform had to match exactly and made Tripp remove the spandex. Everyone wears spandex under their uniform in soccer and lacrosse and other sports. I don’t know why running has to be so fascismo. Especially when there is no physical contact. I mean, it’s understandable that you can’t wear a big chain around your neck in soccer, when you could whip someone in the face with it going up for a header. But running?? Besides, have you seen the kind of jewelry Gail Devers wore at the 100m at Sydney 2000? Â God, track officials are the worst.
Apparently the inside liner of Tripp’s thirty-year old uniform shorts had worn out the elastic, and Tripp had to run most of the race with his hand in his pants holding it all from flopping out. He confessed that early in the race there had been some major slippage and was certain that some of the other racers had gotten a good show. With neither our boys nor girls cross country teams qualifying to go on to states (just three of us qualified as individuals), that was the last day we all spent together as a cross country team, howling over Tripp’s story.
I returned to the bleachers, where my parents had arrived. I checked in with them and then scurried to the track to get in a few last strides in. I was much more confident now than a year ago when I ran my first regional meet as a gawky freshman in clunky Nike sneakers. Â Now, in my featherweight track spikes I knew the drill. But at the same time, everyone knew me.
My jittering intensified as the track officials walked us to the starting line, and my right leg shook uncontrollably. As always, I would let the pack burst out and then reel them in gradually over the next laps. I just had to finish top-4.  I would let the race unfold and let my finishing kick pop into a Q spot, just as I had at last year’s regionals.
‘Ready. Â Set.’
The starting gun shot and the air smelled like gun powder. Nearly twenty girls jockeyed for position. On my second step I felt a chain around my neck clunk against my collarbone, and I realized I had neglected to remove it before the race. I stopped dead and jumped into the infield, all the girls flying by. I fumbled desperately with the clasp, finally got the chain off and threw it in the grass, while everyone else disappeared around the first turn.
By the time I hopped back onto the track the leaders had already completed the first turn. I tore after the pack with a panicked adrenaline, at least 50 meters behind. I trailed the pack alone for the first lap and a half , not seeming to make up much ground.  The only good thing about the mile is that you’re running so hard that you don’t have time to think or get demoralized.
In the second lap I caught the first straggler, then another, and something clicked. Runners were coming back to me, and by the third lap I had pulled myself to the middle of the pack. Entering the final lap, I slipped into my kick. The beauty of the mile is that your lungs are heaving so hard, you’re not registering anything else around you.  People might have cheered as I gained on the girl in the last qualifying position. But all you hear is the thumping in your head, the gasping of your breath, and the wind whooshing by your ears.
I stumbled to a stop and rested my knees on my hands after crossing the line, lungs still heaving. Panting over my knees, I grinned ear to ear. Â I had rallied to overcome what seemed an insurmountable deficit, and I had qualified.
There was a tap on my shoulder and I looked sideways to see an obese man busting out of the front buttons of his official’s uniform and donning an ill-fitting cap. He carried a large clip board.
‘Um, missy. I am afraid you are disqualified.’
I still hadn’t caught my breath yet. ‘I’m sorry?’
‘No jewelry permitted,’ he said flatly.
‘But I took it off.’ My throat constricted. ‘I only ran like four steps in it.’
‘Rules are rules. Sorry.’
‘But the only one it hurt was me.’ Â My eyes were wide.
I sat down in the grass and placed my head in my hands and sobbed. Coach Flemming and Coach Smart quickly arrived and began discussing the matter with the official, but to no avail.
I’m sure the meet continued and other races were held. I’m sure my friends Rob and Dave ran. I’m sure Alpha demolished her competition and screamed at her relay team for sloppy baton passes. I’m sure the relay won anyway. But honestly I recall nothing else from that year’s Regional championship. Nothing but several hours of crushed sobbing that was met with extraordinarily sympathetic, consoling words from my coaches and teammates. Even Alpha.
After the final race of the day was run, the 4 x 400m relay, I said my farewells to the B-CC track team for the year and followed my parents to our Honda Civic.
As we walked through the parking lot, a thought entered my father’s head. ‘You know, if you had really been thinking, you would have run back to the starting line and taken your necklace off there. That way, you would have just technically started the race late. I’m sure there’s nothing in the rule books that says you can’t start the race late.’
‘I doubt you can start the race late.’
‘I bet there’s nothing in the rule book.’ He thought he had hit on something. ‘I mean, why would they have a rule against starting a race late?’
‘Whatever.’
‘I mean, just if you had really been thinking.’
I had finally stopped crying a half hour ago, but the tears began to well again.
‘Or, I bet if you had just left the chain on, no one would have noticed.’ He had concocted another plausible alternative. ‘I mean, it was just a tiny chain. You brought attention to it by taking it off. You could just have not touched it.’
‘Oh, Bob!’ my mother exclaimed.
But the economist in him was on a roll. Â ‘You know, what you really need to have is a mental checklist. Before each race you go through your checklist of places where you might have jewelry: wrists, ankles, neck, ears, fingers.’
‘I never wear jewelry.’ My hands fumbled with the chain in the pocket of my hoodie. I had eventually retrieved it from the field, but I couldn’t bring myself to put it back on.
‘Well, clearly you wore it today.’
‘I don’t even know where it came from. I don’t wear rings, I don’t wear earrings, I don’t wear necklaces. For some reason I put on that chain last night.’
‘When you went out with your friends last night,’ my mother added.
‘Yeah, I guess.’
‘Well that’s it. It went against your routine,’ my father explained. ‘Routine is very important in sports. That’s why tennis players bounce the ball the exact same way before each serve.’
I had not taken to tennis as a child, much preferring sports like soccer where it was harder to identify discrete errors. But I begrudgingly picked up a racquet from time to time. Probably the last time I had played tennis was in Los Angeles, during what had been billed as a friendly game of doubles with my father and I teamed up against my uncle Jeffrey and his friend David. Jeffrey loves retelling the story about how my dad yelled at me to get off the court when I hit the ball in the net too many times.
My head hung low and I stared at the pavement of Middleburg’s parking lot.  Running was the stupidest sport in the world.  But as the defending state champion in cross country, I could not quit.  My grip on my emotions faltered, and tears streamed down my cheeks again.  I would never be a state champion again.
Question:  Should I be freaked out about Lyme disease?
Answer: (a) It depends on where you live.  In the 1990s there wasn’t much Lyme reported in Virginia.  But in the last decade Lyme has been spreading throughout the Northeastern US, and increasingly into Virginia and parts of West Virginia (a trend that is only likely to continue).  In 2012, 95% of Lyme disease cases were reported from 13 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Vermont, Virginia, Wisconsin.  A number of VHTRC runners have had nasty long-term Lyme infections that knocked them out of commission for long periods of time, highlighting the need for knowledge and awareness of Lyme in our running community.
For years, the CDC has reported around 30,000 cases of Lyme in the US a year.  Last year the CDC reported that the methods it has relied on has under-estimated Lyme in the US by a factor of TEN and more like 300,000 Americans are infected each year.  I interpret this as an admission that we really don’t have a clue how many people are infected with Lyme (a 10-fold difference in estimate is HUGE), and reflects how methods of reporting, diagnosing, and estimating Lyme prevalence in the US remain as much art as science.
Answer: (b) It also depends on the time of year.  The spirochetal agent of Lyme disease, Borrelia burgdoferi, is transmitted to humans through a bite of a nymphal stage deer tick Ixodes scapularis.  The highest risk for disease transmission to humans occurs during April – September (peaking  in June-July) when the activity of deer tick nymphs is highest.  However, adult deer ticks are still active in cooler fall months.
Answer (c): Ultra runners are particularly at risk because they spent so much extended time in the woods, are often too exhausted after 24+ hours of activity to bother with anything amounting to a thorough tick check, and are tough, indepedent buggers who are more likely to wrestle with chronic symptoms than to seek medical treatment.  Some well known runners have had debilitating and long-term battles with Lyme, including years of symptoms and misdiagnoses by doctors, including Dusty Olson and Burt Yasso.
Question:Â I got bit by a tick. Â Should I freak out?
Answer: If you got the big fatty dog tick you’re in the clear — they don’t carry Lyme.  It’s the smaller deer ticks (and the tiny deer tick nymphs, which are approximately the size of the head of a pin) that are less likely to be detected while engorged and of greatest concern.
Question: I think I got a nymphal deer tick. Â Am I screwed?
Answer: Only if the tick has been attached for over 24 hours.  Infected nymphs begin to transmit Lyme approx. 36 hours after attachment. The nymph increases in size as feeding progresses (see below), so you can estimate the duration of feeding and probability of transmission based on the tick’s appearance and size.
Question: Â This is complicated. Â Can’t I just wait and see if I get a bulls-eye rash?
Answer: An estimated 70-90% of Lyme cases present with a distinct bull’s-eye rash (called a ‘erythema migrans’ (EM)) that emerges after a delay of 3-30 days (average is about 7 days).  But this truism has made it much more likely for cases with rashes to be diagnosed by physicians and cases without to go undiagnosed, so this estimate is biased.  Rashes may also appear on one’s back or in an area that is not readily visible.  Aaron has no recollection of a rash from his case.  Other clinical signs of Lyme include: facial or Bell’s palsy (loss of muscle tone on one or both sides of the face), severe headaches and neck stiffness due to meningitis (inflammation of the spinal cord), pain and swelling in the large joints (such as knees), shooting pains that may interfere with sleep, heart palpitations and dizziness due to changes in heartbeat.  Even without a rash or any of these symptoms it may be prudent to take a prophylactic regimen of doxycycline antibiotics if you think you have been exposed to Lyme. Â
Question: Why are doctors (like the infectious disease doc Aaron visited) sometimes reluctant to test for Lyme?
Answer: If you have the bull’s-eye rash, you’re in good shape — even a dolt doctor will know to order a Lyme test or even just put you straight on antibiotics.  But if you don’t have the rash or swollen joints, it can be hard to diagnose Lyme clinically, as other symptoms tend to be variable and non-specific and could be caused by a host of other pathogens (there are even other tick-borne illnesses in our region) or conditions (chronic fatigue, fibromyalgia, etc.).  Lyme falls into that grey category of illnesses with non-specific chronic symptoms like fatigue that are hard to pin down.
Furthermore, there is no ‘gold standard’ culture test for Lyme that actually isolates the pathogen.  Instead, docs have to rely on indirect measures of Lyme infection based on human antibody immune responses to the pathogen found in the blood.  But these immune responses aren’t detectable immediately and may take several weeks to develop.  ELISA are cheap and easy first screens, but aren’t reliable due to their high false-negative rate (may miss over half the true cases), and a more rigorous Western blot array that tests for multiple antibody proteins in the blood (if you’ve ever taken Molecular Biology in college, chances are that one of your first lab assignments was to perform a Western blot using gel electrophoresis to separate proteins based on the length of the polypeptide).  The interpretation of the Western blot is based on an algorithm of how many antibodies come up positive (i.e., one positive protein is not enough for a diagnosis of Lyme).
Doctors that are not in high-risk Lyme areas that aren’t used to performing these tests might not know quite how to interpret them (and may therefore be reluctant to administer them). Â Your best bet is to seek out a doctor in a high-risk Lyme area who has seen lots of test results and has developed a feel for distinguishing a positive from a negative. Â In Aaron’s case, his test ‘lit up like a Christmas tree’ and there was no ambiguity.
Question: Will use of insecticide help keep ticks off me?
Answer: Use of DEET is recommended as a deterrent for ticks.  A chemical called Permethrin is stronger, but is highly toxic to cats.  It’s recommended to wear long pants and stay out of tall grass, and that recommendation holds for non-running activities when possible (ie, volunteering).  Thorough inspection for ticks post-woodland adventure in all parts of the body is the key.  When I run with someone through a tall grassy area I typically call out Tick Check! at the end to inspect the legs.
Question: Why is there no vaccine for Lyme?
Answer: I will try to contain myself here, as this question is an excellent one but the answer makes my blood boil.  There actually was a vaccine LYMERix that was licensed by GSK in 1998 in the US that was nearly 80% effective after three doses.  Between the time of its licensure in 1998 and July 31, 2000, about 1.5 million doses of the vaccine were distributed.  But anti-vaccine lobbies are extremely strong in this country, and the media loves a good scare story.  Although science showed that all claims of arthritis caused by the vaccine were bogus, headlines like “Concerns Grow Over Reactions to Lyme Shots,†“Lyme Vaccine May Cause Problems,†and “Lyme Disease Vaccine’s Safety Is Questioned†all appeared in 2000 and 2001, and the vaccine manufacturer discontinued production in 2002, citing insufficient consumer demand.  Following this experience, it is highly unlikely that another vaccine manufacturer will try to enter the US market for a Lyme vaccine.  A Lyme vaccine for dogs is available, although its effectiveness less certain and tick control practices are encouraged even with vaccination.
Question: So, should we just shoot all the deer?
Answer: Even though it’s called a ‘deer’ tick, the ecology of Lyme is complex, and smaller rodents like the white-footed mouse are thought to be key reservoirs.  It’s thought that suburban sprawl has increased rodent populations by removal of predators (like foxes) and replacement of old continuous woodlands with meadows and patches, increasing Borrelia prevalence.
Question: What about those people who never get over their Lyme?
Answer: Lyme remains poorly understood on so many levels and I’ve only begun to delve into the many factious Lyme issues of the day.  Some of the biggies are whether Lyme disease also occurs in Southern US regions and is hugely undiagnosed and whether a form of chronic Lyme can persist following antibiotic treatment.  These issues have yet to be resolved, and there’s not enough science for me to have an opinion yet, but if you’re curious, there’s a lot of information on the web:
American Lyme Disease Foundation
NY Times section on Lyme Disease prevention
[Note – this is a blog written by Aaron.  I pilfered it directly from Aaron’s secret blog]
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“You HAVE to go to a doctor!â€
“Yeah, I guess.â€
“Seriously… I’ll make an appointment for you. Your fever was 101 yesterday, and it’s 102 today. A 102 fever is a legitimate, doctor-worthy fever.â€
“Alright.â€
Martha was right. I needed to see a doctor. It had been several days since Highland Sky 40 Miler. Martha and I started the race together. After 10 miles, I was struggling to match her pace. After 20 miles, I told her that there was no way I could keep up with her, so she should go ahead. After 40 miles, I dragged my feet across the finish line, spent, as exhausted as I’ve been after 100 milers. And while I should have started to feel better in the following the race, my condition declined day by day as my fever rose. By Wednesday, I hit 102. I was able to get an appointment for Thursday afternoon.
“Are you going to be able to make it to your doctor’s appointment this afternoon? I think my mom can take you if you can’t drive yourself.â€
“No, I can make it.†I was starting to feel better. I even considered cancelling the appointment. “I’ve been thinking, though… This illness… I’m not snotty or coughing, and my stomach feels fine. There’s no respiratory or gastrointestinal component. That’s sort of odd, right?â€
“Yeah, it is,†she agreed.
I was looking for some validation for a wild theory. Since she is an infectious disease researcher, I could defer to her judgement. “I was thinking about the last few months. Remember a couple of weeks ago, when we did that long run? Remember how much I struggled? You could hardly run slow enough for me to keep up. All of our runs have been like that recently.â€
“I don’t know why. It’s so weird!†It was a sentiment that she had expressed many times in the past, as I had found it harder and harder to keep up with her.
“And not just recently,†I continued. “The last few months have been really bad, but I’ve been struggling for longer than that. I really haven’t been able to run long for a couple years. Everything over an hour reduces me to a shuffle.â€
“Right.â€
“What if this fever is related to all of that? I mean, the obvious assumption is that I’m just sick because I was immunocompromised from the hard effort of the race last weekend. But what if I was sick before that? All of the difficulty and fatigue I’ve had over the last couple of years could be the real thing, and maybe this fever is just a new symptom.â€
“That could be,†she agreed.
“So I looked at my race result, you know, for my entire race history — all the marathons and ultramarathon and everything over the last decade. Every year, I was getting faster and faster, winning and placing in more races every year through 2009. Then, I ran well in the Spring of 2010, and had a good race at Massanutten 100 Miler. I remember pulling a few ticks off of me at the end of the race. And I remember some other racers did the same. That was the turning point. After that, I had a couple of good races, but overall, that was a turning point. After the Spring of 2010, I was nowhere near the runner I was before then. Maybe I have Lyme disease, and it’s been progressing slowly over the last three years.†It made sense to me, but Lyme is a hypochondriac’s delight. It can present as a wide variety of symptoms; any sort of malaise or general achiness could be falsely flagged as Lyme. If Martha was skeptical, I’d drop it, and leave the diagnostics to the professionals.
“Hmm… That’s interesting… You should definitely ask the doctor to test you for Lyme.â€
My fever broke an hour before the appointment. I arrived at the doctor’s office feeling like the trip and my concerns had all been wasted effort. Despite feeling like it was a long shot, I did request that the doctor test me for Lyme. She declined, dismissing my self-diagnosis with barely a second thought. As it seemed that I had made an abrupt recovery, there wasn’t much to do, other than send me on my way. I did try to get some conjecture about what sort of illness I might have had — what could have made me so sick, with no respiratory or gastrointestinal symptoms. I knew that aside from my own curiosity, Martha would be interested in a firm diagnosis. But the doctor was unable or unwilling to provide an answer. So drove myself home, where I promptly started shivering, and my temperature returned to 101.
The doctor called me the following day. “Hi, I know that you wanted a diagnosis. I was thinking about your case last night. I think I know what the problem was.â€
“Great!†I was thoroughly sick once again, and I was happy that the doctor was giving me some attention. “What is it?â€
“I think you are suffering from heat exhaustion from the race you did last weekend.â€
“Heat exhaustion?â€
“Yes,†she explained, “when you work very hard, you body’s ability to cool itself sometimes…â€
“No, I know what heat exhaustion is. I’m just not sure that that’s the case. The weather during the race was fine. It was overcast, and in the 60s for the whole day.â€
“That may be,†she continued, “but it was 40 miles. That’s an extremely long distance to run. Even on a cool days, it is a tremendous stress to your body.â€
“I mean… You know… I know it sounds like a long way. But in the grand scheme of things… You know… The big picture… Like, I’ve done a lot of races that long. And longer! I don’t think that that’s anywhere near my limit.â€
“What you need to remember, though, is that now you’re 36, not 16. I’m not saying that you’re ‘old’ by any means. However, you are at an age where perhaps you need to dial back your expectations of what you can do. People just aren’t made to run long distances like that.â€
There was only one possible response. “Thank you,†I told her, “I’ll keep that in mind.†I needed to find a new doctor.
The next doctor was an infectious diseases specialist. Due to factors out of my control, it was a week before I was able to get an appointment. By then, my fever had mostly subsided (though on any day, I might be running a slight temperature). Unfortunately, an array of new symptoms started to present. I was extremely tired and occasionally dizzy, I developed severe skin sensitivity and I would drench the sheets with sweat every night. Martha wanted to come to the doctor with me. I was happy to have her as an advocate who could talk to the doctor with more authority than I could.
The infectious diseases doctor performed a routine examination, and ordered some standard blood work. He confidently declared that I would be better within a week. Martha pushed for a specific diagnosis. “Enterovirus,†he said. But Martha didn’t buy it. She tried to debate him, explaining why she didn’t think that was a likely diagnosis. She asked him to test for Lyme. We brought a copy of my race results in the hopes that we could quantify my decline. The doctor glanced through them, and declared that while my times are a little slower than they once were, I’m still faster than most people. “If you had Lyme, you wouldn’t be able to run a three hour marathon!†We tried to explain that a three hour marathon is a world away from the 2:35 marathons I had been running fairly regularly before 2010. Still, though, he refused. “It’s an enterovirus. You’ll feel better in a week.â€
As we left the office, Martha ranted, “He doesn’t know! He has no idea! We’re supposed to respect the doctors, like they have all the answers. But he just felt your lymph nodes and made a guess! It’s… It’s… I’ll tell you what it is: It’s medieval! He might as well set some leeches on you! He might as well say that your humors are out of balance! We need to make an appointment with Dr. H!â€
“You think we’ll get a different answer? I’m not sure it’s worth making an appointment with yet another doctor.â€
“Dr. H will listen to you. You’ll need to be assertive, but he’ll listen.â€
Dr. H was on vacation, so it was yet another week of fatigue and illness before I could get an appointment. At some point, I started tracking my symptoms. Each day was a different set of symptoms: fatigue, night sweats, rashes, skin sensitivity, dizziness, nausea, and most concerning, arrhythmia. Some days were better than others, but even on my best days, I was in a constant fog, napping several times a day to stay functional.
When the time for my appointment arrived, Martha briefed me on Dr. H. “You need to be assertive. He’ll listen to you, but you need to be assertive.â€
“Assertive. Got it.†But I didn’t have it. I wasn’t entirely prepared for his line of questioning.
I happened to be having one of my better days when I saw him. He started the consultation by asking, “What symptoms of the illness you called about are you experiencing right now?â€
“Right now? Right now I’m not experiencing any symptoms.â€
“Okay, then what symptoms were you experiencing on the day that you called to make the appointment?â€
“Well, on that day, I believe that I was a little bit fatigued, but I was generally alright.†I spoke from the perspective of someone who had spent the previous month waking up in the morning not knowing whether I would be able to get out of bed during the day, and grateful for the days when I felt relatively normal.
Dr. H, however, was approaching the problem systematically, with the assumption that I was a patient looking for a diagnosis of an illness that was proceeding in an arc of several days or weeks. Growing impatient, he sighed. “When you called to make the appointment, there was some reason, right?â€
“Yes. Absolutely. Maybe I should just describe the situation from the beginning…â€
“No, no, no,†he cut me off. “I think I know how to get the information I need. Let me ask you several questions, and we’ll figure this out.†He proceeded to ask me a series of questions that did allow me to describe the range of symptoms I had experienced in the preceding month. I described my progression from what seemed like a standard, febrile illness to one that involved a strange array of ever-shifting symptoms that might present or not on any given day. By the end of the interview, he had received a fairly thorough picture of the month since I first started experiencing acute symptoms. “So,†he was ready to conclude, “at this point your primary symptom is the extreme fatigue you described. You are starting to feel better than you have, but you want to know of there is any treatment that can help your recovery. Is that a fair statement of the problem?â€
I took the opportunity to respond to the first open-ended question he had posed. “No! The real problem is that for the past decade I’ve been a fast, competitive long distance runner. I was getting faster and faster every year until the Spring of 2010. I had several good races in the Spring of that year, then I did a long trail race. At the end of the race, I pulled several ticks off of me. I thought I got all of them, but ever since then, I’ve been struggling with my running. My race standings dropped precipitously. I’ve been getting slower and slower. By this summer, every run would leave me exhausted. It was only due to this past month of severe, acute illness that I finally took a look at the larger picture to put everything together. I think I got Lyme disease at that race in 2010. I want you to test me for it.†It had all come out in a single breath, blurted without a pause or break.
Dr. H paused for a moment, in case I had any more to say. “Well why didn’t you tell me that earlier? We’ll test you for Lyme and babesiosis, for Epstein-Barr and Cytomegalovirus…†He probably listed a few others, but I don’t recall what they were.
A week later, the doctor’s office called. “Your test results came back. Everything was negative except for the Lyme test. Dr. H wants to start you on three weeks of doxycycline as soon as possible.†(In a follow-up visit with Dr. H a few weeks later, he insisted on showing me my lab results. He assured me that while the raw results aren’t of interest to most patients — they require a bit of interpretation — mine were noteworthy because they, “lit up like a Christmas tree.†Apparently, according to the test, I was as clearly and thoroughly infected as someone could be.)
Many people who receive delayed treatment for Lyme experience prolonged or chronic symptoms. I was tremendously fortunate in that the antibiotics had an immediate effect. Within two days, the acute symptoms had disappeared. Within 10 days, I was feeling better than I had in at least a year. Within a month, I was an entirely new person.
By the Spring of 2013, before my symptoms had become acute, I had come to accept that I could no longer run competitively, that at the end of the work day I would only have the energy to make it to the couch to collapse with exhaustion, that every morning, no matter how much sleep I got the night before, I would wake up dizzy and exhausted and never feel fully rested. Over three years, I had aged three decades. The process was so steady and gradual that I never quite noticed it. Then I took three weeks of antibiotics, and then another three weeks (which I requested after hearing the consensus among many long-term Lyme sufferers that three weeks is not enough), and in the following three months — from the middle of August to the middle of November, I gained back those three decades.
As I write this, in the first few days of 2014, I’m excited about the future. If there are lingering effects of the Lyme, they are small. I have run one race post-Lyme — a 100km race I run every year. I felt better at mile 60 this year than I felt at mile 10 last year. Looking back, it’s hard to believe I dragged myself through that distance last year in the state I was in. I haven’t yet regained all the fitness I lost, but I’m on my way. And now that I’m healthy again, everything feels just so much easier.