Having to withdraw from Norseman was painful. Not so much physically painful as emotional painful. As I mention in the Race Report from Norseman 16, it did hurt a lot to bring so much fear to my loved ones.

Failures are often the best ways to learn, and the bigger the failure the steeper and longer the learning curve is. Coughing bloody phlegm was not a nice experience, but coincidences actually made the experience a unique way to learn about the strain of extreme endurance races. Since I signed up for the Norseman research project 2016 I got thoroughly tested the day before the race. Blood samples were collected and lung functions tested. In cooperation with the awesome medical crew at Norseman I have gotten the best possible checkup afterwards and that combination is something no one (of my knowledge) with swimming-induced pulmonary edema, SIPE, have had before me. The data just could not have been better.

While I do not have all the answers, I have a lot of answers. At least I know what is not wrong.

Pulmonary embolism (blood clots in the lungs) was not the cause. While the CT-scan clearly showed internal bleeding from the upper part of the chest right after the race, it was normalized a few days after. The spirometry-test the day before the race and 5 days after the race was quite similar, with 122 % compared to 121 %. The measured blood values, blood pressure, heartbeat etc. were also normalized a couple of days after.

Having the most thoroughly CT-scan possible of the heart was incredibly valuable. With the best and newest equipment and the highest expertise in Norway, we checked every angle of the heart, both resting and under a workload of 50, 100 and 250 watts. The heart was in perfect shape which did not give us any answer regarding my breakdown, but who else have such a good insight of their own heart?

So what was the reason to the lung failure?

While I do not have the expertise to give you a 100 % medically answer, I will share my theories. There is likely not one reason, but a series of unbeneficial factors that made “the perfect storm” and ultimately caused a lung failure so big that I could to keep up anymore. The unbeneficial circumstance’s was:

• Cold water – It was not super cold, but surely not warm
• High compression on the chest while swimming – Compression from the wetsuit, the special hood, extra shirt under the wetsuit gave a high compression on the chest. Compression leg sleeves also increased the overall compression.
• “Overhydrated” – Since I have a higher than normal carbohydrate level right before a race due to decreased activity level in the taper period, the level of water that follows the carbs is also higher. This may also increase the pressure outside the lungs.
• A very high workload over time – The lungs work hard for many hours
• Cold weather – The conditions were worse than expected. It was my fifth go at the race and we were very well prepared regarding clothing. Still, it got worse than I imagined, and a bit worse than the already quit bad weather forecasts.
• Insufficient clothing – I did not get cold before we reached Haugastøl, at a point where I had about 30 min left to Geilo. My decision was to not put on more clothes at that point since it gets warmer after Geilo in the uphills. Last year I was well dressed acrossing Hardangervidda, but got a bit warm after Geilo. Therefore I thought I could pedal myself up to heat going towards Dagali. That certainly did not happen, and when I put on more clothing at Dagali the damage was done and I did not get the body temperature back.
• Low body fat – Of the elite athletes at Norseman we are all skinny, but I am most likely the most skinny one with a body fat percent of 7.4 measured with a DXA-scanner. That was nearly 5 % down from last year. From a performance perspective that would usually be positive since my threshold power/speed has not declined. 3.5 kg less weight is noticeable in the uphills. What is also noticeable is a quicker loss of body temperature and difficulty to regain it afterwards. That may be a reason why I failed were my competitors did not.
• Inhalation of water during the swim – Since it was quite a lot of waves during the swim I cannot rule out that I inhaled water in my lungs during the swim

In addition there is also unbeneficial factor that was not present.

• Gender – Females get more often SIPE than males
• Intake of fish oil – I do not take Omega 3 supplements, but do eat a lot of fish
• Use of inflammatory medicines – I use nothing

A simple answer to why I got my condition under the race does not exist. SIPE fits the symptoms well, except from I did not get it acute during the swim, but three hours out on the bike before I noticed any performance decline (watt and heartbeat) and another two hours before I cough up the blood. The answer I have most faith in at this moment is “the perfect storm”-theory were a combination of the unbeneficial factor just overloaded the lungs.

How can I avoid it again? Well, it seems like it is no guarantee to avoid a similar condition in the future. Some people have experienced SIPE several times, but most people have gotten it only ones. My measures for not letting it happen again are:

• Proper clothing – Even if that will mean that I have to stop and completely redress.
• Avoid overhydrating – Aka not take salt tablets and drink so much electrolytes before races
• Improve breathing during high intensity swimming – Get a more steady and relaxed breathing also under hard effort.
• Gain a few pounds – A bit thicker layer of fat would probably be positive regarding the ability to maintain body temperature in cold conditions and overall health in the long run.

My next race will be the very first official Lofoten Triathlon this Saturday, which I did the test version of last year. 4 k swim in 13 – 15 degrees water, 196 km bike ride and 45 km run passing two mountains. It may sound a bit hard a bit early, but for me it is the perfect test. I will of course be extremely sensitive to the signals from my body and quit immediately if I think anything is not right. Proper clothing is also highly prioritized. The positive thing about SIPE is that the damage usually is recovered after a few days, so since I don’t suspect that I am not 100 % recovered in any way, a physical test is the only way to prove that the lung failure was temporarily, caused by the factors above.

I am really looking forward to another stay in Lofoten, because of the amazing nature and warmth of the people. The race is also awesome and I cannot wait to give it a go with so many others!