A runner gets treatment during the 2017 Ultra Gobi.
A runner gets treatment during the 2017 Ultra Gobi. (Photo: Sam Westall)

The Medics Keeping Ultrarunners Alive

With more participants in ultramarathons, more competitors are experiencing the joy of hallucinations and other ailments. Exile Medics steps into a newly necessary role.

A runner gets treatment during the 2017 Ultra Gobi.
Will Ford

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On the third day of the Ultra Gobi, a 250-mile race in the vast Chinese desert in late September, elite British ultrarunner Nathan Montague was hallucinating. He’d gone more than a 130 miles, and a stretch of dirt road in an empty valley had suddenly became a parking lot jammed with cars, perhaps on a highway or a rental lot at an airport. Someone—an attendant maybe—informed him he had to return his car. But it was far away in the distance, so Montague asked whether the attendant could return it for him. He grew more confused. The keys were no longer in his pocket, and hadn’t he given them to the attendant? Then the parking lot disappeared, and Montague again found himself in the remote desert, with the northern edge of the Tibetan Plateau looming in the distance.

The previous night had been rough as well. After making his way down from the race’s high point at an elevation of over 13,000 feet, Montague arrived at a rest station shivering uncontrollably. I was reporting at the Ultra Gobi, and I slept in media tents at the rest stations, doubling up on sleeping bags and gauging the temperature, which could dip into the low teens at night after hitting daytime temperatures as high as 70 degrees, with plastic water bottles. When Montague arrived, the bottle next to my pillow had frozen solid. One of the doctors stationed at the rest point woke me, asking to borrow the extra bag. Montague was becoming hypothermic, and James Poole, another British runner who arrived shortly after, was also at risk. The race leaders had been hallucinating as well when they’d come through a few hours before.

Liang Jing, the Ultra Gobi's 2018 champion, takes a rest at the race's high point, at over 13,000 feet.
Liang Jing, the Ultra Gobi's 2018 champion, takes a rest at the race's high point, at over 13,000 feet. (Will Ford)

That night the two young British doctors, Rosemary Hartley and Nico Swetenham, made a rule. Anyone with a core body temperature below 96.8 degrees Fahrenheit, which they later lowered to 95, wouldn’t be allowed back onto the course. Inside the rest tent, Montague and Poole recovered in their bags and draped themselves in jun dayi—enormous, Mao-style green fur coats used by the Chinese army, which volunteers kept at the rest station. Their core temperatures recovered in a few hours, and the doctors let them go.

After a few days on the course, it was hard to imagine the event running safely without the doctors provided by Exile Medics, a British group founded in 2009 that provides medical services to remote adventure events all over the world. Xingzhi Exploring, the Chinese race organizer of the Ultra Gobi, had been required by the local government to hire a medical team. It was a large investment—just under $18,000—and not one that most races make, which speaks to the moment in which ultraracing now finds itself: for the most part, it’s still up to race organizers to decide how much medical support to provide, even as the sport has grown increasingly mainstream. Whether they should even have such standards, and how far they should go, are unresolved questions.

“I mean, it’s not really good for you,” the American ultrarunner Mike Wardian told me once, describing any race longer than 100 miles.

In a space where pushing limits is often the point, it’s not clear how much medical support ultra organizers ought to provide. During competitions, ultrarunners experience (and assume the liability and risks for) a wide range of medical challenges, ranging from blisters to hypothermia and heatstroke. In recent years, races have occasionally even seen deaths. Karl Hoagland, the publisher of UltraRunning magazine, has been tracking ultra-race completions for a few decades and, according to his database, about 30,000 runners finished ultras in 2008. Last year, that number reached 110,000. With the uptick in participation, and more novices getting involved, questions surrounding standards of medical care—which there’s no global organization to set—are being asked more frequently.

In a space where pushing limits is often the point, it’s not clear how much medical support ultra organizers ought to provide.

“I don’t believe there is a standard. The sport is growing up, and regulations for various aspects of race production are starting to come more front of mind. But who is the institute to put these regulations into place?” says longtime ultrarunner Krissy Moehl, who recently directed her first race in 17 years. “The medical piece is one of the discussions.”

Hoagland agrees. “I don’t know of any formal standards of medical care for ultras,” he says, adding that the sport’s core values emphasize independent adventure, something that medical care should be careful not to spoil. In races, runners are expected to self-regulate, deciding when to rest, eat, or seek help—sometimes from other racers. “The ‘nanny state’ regulates our daily lives to a great extent,” Hoagland says, “and ultras are a break from that. Trying to bring proactive, overinformed, and intrusive medical oversight to ultras is not practical or prudent, and it detracts from the sport.”

Most athletes I spoke to agreed with that sentiment, though with caveats. Montague feels the sweet spot falls somewhere in between allowing athletes to make decisions on their own until they enter a state where they may not be able to do so by themselves. And that’s where good medical supervision should take over, he says, providing a kind of safety backup that doesn’t cheat the experience of subjecting oneself to pain.

“As ultrarunners, we’re exploring our limitations. But on any given day, these can be transient,” Montague says. Exile Medics tries to manage this line delicately by being respectful of runners’ desire to push themselves, while helping them avoid unreasonable risks. By now the organization has had ten years of experience managing medical care with this balance in mind at races all around the world—China, Namibia, Costa Rica, Sweden, Sierra Leone—averaging about 25 to 30 races per year. Brett Rocos, the founder and director of Exile Medics, says, “Our experience means that we can tell between an exhausted, emotionally drained athlete and a person with genuine illness.” Still, the medics do their best to let athletes make decisions about potential risk themselves, accepting that even as medical professionals they can’t control all the dangers and making sure runners know that. If a runner is hard-set on continuing despite medical issues, Exile Medics often lets them go, provided the ailment isn’t extreme, like hypothermia.

A race with extremes that could so easily bring on hallucinations felt, at times, like it was bordering on dangerous.

At the Ultra Gobi, Exile Medics navigated that line well. Later Montague told me he might have gone back out prematurely that night if Exile Medics hadn’t kept him inside—a doctor’s order he now appreciates. But the team also let the athletes push themselves. After the race, I spent a lot of time interviewing runners about their hallucinations—conversations, I admit, that I found comically entertaining in some cases. Seemingly everyone—across all races, nationalities, and sexes—left reality at some point. Rocks turned into animals, abstract art appeared in the skies, family members showed up out of nowhere, bushes transformed into giraffes. The visions frequently bordered on the magical, a kind of acid trip without the drug, and participants told me they deeply valued those experiences, untethered from the mundaneness of reality.

On the other hand, a race with such extremes felt, at times, like it was bordering on dangerous. Samantha Chan, a participant at previous Ultra Gobis, remarked that while most desert races felt like social walks with friends, the Ultra Gobi was a gauntlet. But with a trained medical team on the course, almost 80 percent of the runners completed the race.

Hoagland told me he expects the growth in ultrarunning to continue. And with it, pressure for race organizers to provide more medical supervision will likely also increase. But for a sport that pushes its athletes to extremes, expecting races to be held responsible for every health risk is probably unreasonable. “With this sport becoming more mainstream, and more people than ever involved, the risks are greater,” Montague says. “So both race directors and organizers have a greater degree of responsibility to negate these risks, to protect these individuals from themselves. But ultimately, the duty of responsibility needs to be taken by the athlete.”

The Ultra Gobi, at least, seemed to strike the right balance. Before everyone departed, the Exile Medics staff shared beers on the rooftop of a local hotel with some of the athletes. The mood was jovial. Runners swapped stories of hallucinations and pain, recounting them now with laughter and awe. Around the table, athletes and medics alike shared a sense of accomplishment. I heard no regrets. On their walks to bathroom breaks, most participants were limping, but they would recover soon enough.