Inside the Final Miles: How Race Day Unfolded

Pieced together from her family’s accounts and statements reported by CBS News, The New York Times, NBC News and others, the sequence on Nov. 1 looked like this. Mile markers are confirmed; clock times other than the time of death were not published.

• StartApa begins her first marathon, a 26.2-mile course through all five boroughs, running on the Parkinson’s Foundation charity team.
• Mile 13.1She passes the halfway point. Her father is tracking her progress through the race app and sending messages.
• Miles 18 to 19She replies only twice after halfway, both times saying she is in pain.
• Mile 23Her father sends encouragement as she enters the closing stretch. Her mother waits farther up the course near Mile 25.
• Mile 24She collapses in Central Park near 85th Street. Spectators, two of whom said they were doctors, take turns giving CPR.
• Minutes laterRace medical staff take over and use a defibrillator before an ambulance transports her to Mount Sinai.
• About 6 hoursDoctors continue life-saving treatment. She is pronounced dead at about 9:40 p.m.
• Nov. 3 to 4The medical examiner’s office says it is still investigating. Her father tells reporters the cause was rhabdomyolysis.

Muscle Under Siege: What Rhabdomyolysis Does Inside the Body

Every hard run causes microscopic damage to muscle fibers. That is how training works: the body repairs the damage and rebuilds stronger. Rhabdomyolysis is what happens when the damage outruns the repair. Muscle cell membranes fail on a large scale, and the contents of those cells pour into the bloodstream faster than the body can clear them.

Three of those contents matter most. Myoglobin, the protein that stores oxygen in muscle, is filtered by the kidneys and can clog and injure them, especially when a runner is low on fluids. Potassium, normally locked inside cells, can surge in the blood and disrupt the heart’s electrical rhythm. Creatine kinase, or CK, is harmless in itself but is the main lab marker doctors use to confirm the diagnosis and track its severity.

Why the Heart, Not Only the Kidneys, Can Be the Danger Point

Kidney injury from rhabdo usually develops over hours to days, which is why many runners with exertional cases recover once IV fluids start. A sudden potassium spike moves faster. High blood potassium, known as hyperkalemia, can provoke arrhythmias and cardiac arrest. It is one reason a collapse during a race can involve several overlapping processes, including heat illness, electrolyte shifts and muscle breakdown, that may be hard to untangle until a full medical review is complete.

Rare but Real: The Numbers Behind Exercise-Related Rhabdo

In absolute terms, rhabdomyolysis is uncommon. A 2016 review in BMJ Open Sport & Exercise Medicine cited an estimate of about 26,000 U.S. cases a year from all causes, with exertional cases making up 47% in one report, though other studies found smaller shares. Many milder cases in distance runners are never diagnosed. Emory cardiologist Jonathan Kim, who has co-authored large studies of 23 years of U.S. marathon and half-marathon death data, told CNN that race deaths are extremely rare and deaths from rhabdo rarer still.

The gap between those figures is the point. Across every cause, including crush injuries, drug toxicity and infections, kidney injury is common. Among otherwise healthy people hospitalized for exercise-related rhabdo in a Kaiser Permanente Northern California study published in JAMA Network Open in 2024, the rate was far lower: 17 of 200 patients, and none died. That is why doctors describe a fatal case in a young runner as exceptional, not typical.

The Heat Signal Hidden in Six New York City Marathons

The most relevant research comes from New York itself. Physicians at Mount Sinai and Lenox Hill, including nephrologist Douglas Farrell, reviewed hospital charts for rhabdomyolysis after the 2017, 2018, 2019, 2021, 2022 and 2023 marathons. The 2020 race was canceled because of COVID-19. Their findings appeared this year in the journal Nephron.

One year dominated. The 2022 race, the warmest since the event moved to November in 1986, reached a peak heat index of 24.5°C, about 76°F, and produced 24 cases of post-marathon rhabdo. The other five races combined produced about 15. Heat index and case counts moved almost in lockstep, with a correlation of 0.93, and race day in 2022 was 5.6°C, about 10°F, warmer than the previous two weeks, the biggest jump of the period.

The authors pointed to acclimatization. Runners who had trained through a cool autumn met sudden warmth on race day before their bodies had adapted to shed heat efficiently. They described the link as a correlation rather than proof, and the sample was small. It also matters that the 2026 race was not a 2022-style heat outlier: forecasts called for the 50s to around 60°F, though some outlets described temperatures reaching the mid-60s. Heat is one piece of the puzzle, not a full explanation.

What the Bloodwork Revealed

CK readings in the Nephron group were striking. The average on arrival was 5,515 units per liter and the average peak was 21,426, with one runner reaching 88,430. Runners who arrived feverish peaked far higher than those who did not. Nearly all had some kidney injury, yet almost every case was short-lived and responded to IV fluids. One runner needed dialysis for about two weeks and then recovered.

The Painkiller Habit That Kept Showing Up in the Data

If one practical lesson stands out, it concerns over-the-counter anti-inflammatory drugs such as ibuprofen and naproxen, known as NSAIDs. In the Kaiser study, 64.7% of patients who developed kidney injury had used NSAIDs before admission, compared with 21.9% of those who did not. The researchers estimated that eliminating NSAID use and dehydration could have prevented 92.6% of the kidney injury cases.

The New York data echo that at small scale. The only runner in the Nephron study who needed dialysis was also the only one documented to have taken naproxen, and he reached the hospital later than the others. NSAIDs reduce blood flow to the kidneys exactly when they most need to flush out myoglobin. The Kaiser authors favored acetaminophen for exercise-related aches. Nothing has been reported about whether Apa took any medication.

Who Faces Higher Odds, Beyond the Distance Itself

Anyone can develop exertional rhabdomyolysis, regardless of age or fitness. Cleveland Clinic sports medicine physician Jessica Tomazic and other experts quoted in recent coverage name a consistent set of risk factors. The table below organizes them alongside the data behind each.

Two cautions keep this in proportion. Most people with several of these risk factors never develop rhabdo, and a first marathon is not inherently dangerous for a healthy, trained runner. At the same time, fitness lowers risk without erasing it. Apa was a lifelong athlete who exercised regularly, according to her father. Earlier in 2026, a 21-year-old Navy SEAL candidate, Austin Stallman, died of rhabdomyolysis after collapsing during a 9-mile training run in Texas.

Sore Legs or Something Worse? Reading the Warning Signs

The difficulty is that early rhabdo can look like ordinary marathon misery. Every finisher hurts. Clinicians describe the red flags as pain out of proportion to the effort, muscles that swell or feel rock-hard, weakness that keeps getting worse instead of better, and urine the color of tea or cola.

Why Dark Urine Is the Signal Not to Ignore

Cleveland Clinic notes that the classic trio of muscle pain, weakness and dark urine appears in fewer than 10% of patients, so missing one piece of the set is not reassuring. Myoglobin tints urine brown. If dark urine follows a long or intense effort, especially with little urine at all, the right move is an emergency department, not a recovery shake. Confusion, fainting or repeated vomiting during a race are emergency signs on their own.

Inside the ER: How Doctors Treat Rhabdomyolysis

Diagnosis rests on a blood test for creatine kinase. Rhabdo is commonly defined as CK above about five times the upper limit of normal, though some definitions use ten times. Doctors also check kidney function, potassium and a urine sample. Treatment centers on generous IV fluids to flush myoglobin through the kidneys, along with close monitoring of electrolytes and heart rhythm. Dialysis is reserved for severe kidney failure or dangerous potassium levels.

Timing is the variable patients control. In the New York study, every patient received IV fluids, and the one runner who needed dialysis had arrived late. Most people with exertional rhabdo recover fully, often within days to a few weeks, but they are usually told to return to training slowly and only after their bloodwork normalizes.

A Race-Week Playbook That Lowers the Odds

None of these steps guarantees safety, and none says anything about what happened to Apa. They reflect the patterns that keep appearing in the research and in sports medicine guidance.

• Build graduallyA common coaching rule is to raise weekly mileage by no more than about 10%.
• Respect the forecastHeat adaptation usually takes 10 to 14 days; adjust goals if race day runs warm.
• Leave the ibuprofen homeAvoid NSAIDs for 24 hours before and during long efforts; acetaminophen is a gentler option.
• Hydrate to thirstSteady sips plus electrolytes beat chugging; overdrinking carries its own risk.
• Skip the race if sickA fever of 100.4°F or higher is a clear reason to defer.
• Listen past mile 18Pain that sharpens in the final 8 miles is a reason to walk or stop.
• Check your urine within 6 hoursDark color or little output after a race means go to the ER.
• Review your medicationsAsk about statins and other drugs that affect muscle before race season.

If You Are Cheering, Pacing or Running Beside Someone

Spectators often see trouble first. Stumbling, confusion or a runner who suddenly stops responding should prompt a call to the nearest medical tent or 911. If someone collapses and is not breathing normally, start CPR and ask for an automated external defibrillator, exactly what bystanders did for Apa. And if a friend texts mid-race that they are hurting, it is fair to ask whether they should stop.