The Life Of The Ultrarunner

Posted by Jeremy Windsor on Feb 12, 2021

Over the years we've dipped our toes in the water and taken a look at some of the challenges faced by ultra runners. Wanting to find out more we asked DiMM holder and neurosurgeon Hian Lim Soh to tell us about his experience...

"I am Malaysian - 4th generation Chinese. On completing my A-levels in 1985I moved to Japan for further study. After completing my neurosurgical training in 2000 I returned briefly to Malaysia, before finally settling back in Japan where I have been in active practice ever since.

Outdoor life started some 8 years ago when I saw a boy hanging from a wall. The adrenaline got me, on sandals, half way up a 6a rock climb. Soon I was on to mountaineering and running quickly followed.

In Japan, road racing have been popular for many years. However, trail running probably started only a decade or so ago, and the 100’s - 100 kilometres and 100 miles - have quickly flourishing, but their popularity remains limited.

My training consists of a 3 hour session every other day. Hospital work decides whether it's 5 in the morning or after dark!

Annapurna Ultra 2018 - an exhausting race at altitude!

I have no special nutritional considerations. Rice is a constant source of carbohydrate and the rest is based upon what I want rather than need. Tougher running is interspersed with lesser load, simply gauged by listening to the joints and muscles. They need to be productive, over-loading the body is necessary to maintain and promote development, but it is very much the case of quality rather than quantity. After every session, I do a minimum of core training, whilst cooling down. When a race is approaching, intensity peaks and when it is over running resumes a few days later. I even trained during the Diploma in Mountain Medicine (DiMM) residential weeks and come rain or shine, snow or monsoon, I'm out there!

A very high standard of organisation can sometimes be found at ultra events - the Tarawera Ultra Marathon in New Zealand is amongst the best!

I've often found that race organisers tend to be over optimistic with their medical rescue capability. Even with access to a local "Search and Rescue" team and nearby medical facilities, it is often difficult to deliver a casualty to hospital within 3 hours. In two long distance events, Shenzen (UTSZ100) and Hong Kong (HK168), professional medical support was absent - not even a first aider was available! In many others, they were only found at very limited locations. However there are exceptions. During the Kinabalu International Climbathon in 2017 they had several doctors and ambulances ready and mountain rescue teams stationed at high altitude locations. Similarly, during the Tarawera Ultra Marathon medics were clearly present, with doctors at stations, pacers willing to run with exhausted runners, some paramedic mountain bikers actually patrolling the trails and a medical tent set up at the finish line. As a minimum, I believe that safety patrols should be stationed on risky terrain and medical specialists should be on standby at the finish line.  

A slippery, tortuous and long descent during the Vietnam Mountain Marathon

The Vietnam Mountain Marathon (VMM) is the only race I have repeated. This is largely because the trail takes you deep into remote tribal mountain villages. Here we were often met by lively children and intrigued looks from their parents! The VMM started with 70km distance in 2015 and back then only two locals got into the top twenty. The next year it stretched to 100km and four Vietnamese were highly placed. I got back for the third time in 2019. Eleven local athletes finished in the top 20 and the top 3 were all Vietnamese! Ultra-trail running is getting increasingly popular in many countries and the athletic level is improving.

Children in Sapa, a town in northwest Vietnam


In the time of Covid, ultra running has been particularly difficult. Social distancing has put off volunteers and has therefore limited access to much needed support. Last year, OSJ Koumi coincided with Typhoon No.14. The route is 5 laps of a 32km circuit. Some 426 runners took part, only 28% finished compared to 41% in 2017. The start was at a mountain village situated at a height of approximately 1000m and the trail peaked at a height of 2100m. Some, myself included, camped in a downpour the night before and started running at 5am in heavy rain. Each runner was entitled to only a single 500ml bottled water at each of the 4 stations along the way. To make matters worse, we had to carry the bottles back to the start line! Here, we were given energy bars and more bottled water, but we were forced to consumed them in a tent or adjoining parking lot. Supporters were only allowed at the start and no mingling was allowed. Typical of circuit races, the path quickly turned to mud. A summit path soon became knee deep and most non-solid trails became swampy. On the third circuit I slipped a few times during a rocky descent. To cap it all, the race organisers decided against providing warm food and drink to competitors at the end. Since I was alone I was left to fend for myself!

A muddy section of the OSJ Koumi in 2020. It only got worse!

Trails are often unpredictable, neither the contour map nor Google can tell you what you'll find on race day. Steep, slippery and rocky long descents are always a hazard and despite all the modern gadgets, getting lost in the middle of nowhere is still my greatest fear! Running these distances is demanding, but surprisingly, major emergencies are rare. More common are muscle and joint troubles, fatigue, upset stomach, extremes of temperature, and ‘scratches’My commonest injury has been subungual hematomas, either the second nail or big toes. Blister are uncommon. I've almost never needed to use medical kit for myself.

A reassuring sight at the Kinabalu International Climbathon!

GPS devices can be way out in the mountains. Route markings were absent in the Kuching Ultra 2020. The route often ran parallel to other tracks and my GPS could not distinguish between them. In 2016's HK168 the route on my pre-programmed GPS took me up to a pathless mountain summit and directed me down a vegetated hillside. On returning to the route I then went the wrong direction at a crossroads and found myself wandering the hills of Hong Kong for half a night. These ‘lost in space’ moments often occur at night when runners are fatigued and visibility is poor. Whilst the Japanese are generally meticulous with their trail marking, others vary and depend upon the decisions of the individual race director.

Long mountain race can see a wide range of temperatures. During the Istria 100 in 2018, the temperature ranged from 8℃ (with snow piled up near the summit of a 1394m peak) to 34 at sea level

In a race it is always easier to deal with cold than heat - keep moving, put on an extra layer and cover all exposed areasNot so for heat. In 2016, the Ultratrail Angkor took place in a drought year and temperatures during the race reached 40℃! Adding to the heat was the dusty village roads with trucks mercilessly flying through. The heat and dirt aerosol made life miserable, even without the running part! My 24 year old French running mate slowed down to a halt and an Australian runner I knew gave up at the halfway point. Caucasians are probably less adaptive to tropical heat. During the 2015 TMBT I witnessed several overheated runners - mainly highly muscular Caucasians - all lying down flat in the shade after just 20km. 

Last year I was pinned down in temperate Japan. I trained as usual and entered the Kuching Ultra, a 100km road race back at home in Malaysia. Heat acclimatization requires time and I was conscious of it, but could only have 2 days. Two hours into the run, the muscles, limbs and trunk, cramped in a way I have never experienced before. Slow pace, plenty of ice cooling and night fall eventually got me through.

Hypothermia can also be a problem in the tropics too. During TMBT some of the top runners were found to be shivering at the end and needed evacuation. Whilst daytime rain has a positive effect upon on exercising bodies, as exhaustion and darkness set in, it can quickly lead to a loss in body temperature.

Recently a runner taking part in a 124km race fell after just 31km and sustained spinal injuries that would eventually require surgical decompression and fixation. The incident took place just 1km from the road. Unfortunately the area lacked a mountain rescue team and the evacuation to the nearest medical centre just 8km away took more than 3 hours

Every runner has their own specific medical complaint en route. For me, an upset stomach nearly always sets in towards the end. It is proportionate to the workload and can sometimes occur early on. I had my worse episode during UTMB when I vomited at 30km and for the next 140km I was only able to consume plain water and chunks of biscuit. Anything more induced outright vomiting! A 40 hour non-stop ordeal.During the  Eiger Ultra Trail in 2016 and the Cappadocia Ultra Trail in 2017 the cold had me. The only solution was to keep moving, however exhausted I was. Warm drink and soup were available in Turkey but only soup and a cold drink in Switzerland, the latter combination upsetting my stomach further. Every 100 race is extreme, but above all of the physical considerations it is essentially a mind game. The last quarter is exhausting and will be very much "mind over body".

When I started running, I used to ask myself, ‘what am I doing!?’, but many moon's ago I realised, ‘I run so I am’".

Thanks Soh!

Ever wondered why ultra runners sometimes walk downhill backwards? Read this to find out more!

Interested in triathlon? Take a look at this. How quickly can a training run go wrong? Read about it here! Like to run the Welsh 3000's? Want to know more about making long distance events safer? Read this!

If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.


The Birmingham Medical Research Expeditionary Society (BMRES) and the British Mountain Medicine Society (BMMS) have joined forces to organise the 2021 Altitude Research Conference. The face-to-face event will take place in Birmingham on the 11th September. Speakers will include Peter Bartsch, Jo Bradwell and Chris Imray. There will also be presentations from members of the UK's leading research groups as well as ample opportunity for researchers, young and old, to present posters and short talks about their work.

Further details can be found here.

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