Slide 1

Medical Planning &
Road Race Management 2006
William O Roberts MD, MS, FACSM
Medical Director
Medtronic Twin Cities Marathon
Associate Professor
Department of Family Medicine
University of Minnesota Medical
• Discuss injury patterns & changes
• Discuss evaluation procedures for Medical
& Safety Operations
• Discuss media management after an
adverse event
• Discuss runner-patient confidentiality
• Discuss assets & equipment: purchase,
rent, or borrow
Why Address Safety & Medical
Operations For Your Race?
# 1 priority Medtronic TCM
Medical events & safety breaches
–Potential for
Bad press
Runner catastrophe
Where to Put Your Money
ALS ambulances & staff
Defibrillators for course
Medical volunteer identification
Communications system
Race Medical Operations
Role in Race Operations
Optimize event safety
Provide medical care
Make medical decisions
Act as medical spokesperson
Race Medical Operations Purpose
–Improve competitor safety
–Prevent excess injury & illness
Race day - Primary
–Stop progression of injury or illness
Race day - Secondary
–Prevent emergency room overload
Race Medical Operations Purpose
–Make it better
Planned Disaster
Mass gathering
–Potential for
Primary goal of medical
–Safety of competitors
Attention to details
–Improves safety
Lincoln Park, Sunday, exactly 6 minutes
23 seconds before the paramedics arrive.
Incidence & risk of injury
Risk ranges
Running (41 km) - 1% to 20%
–TCM - 0.8% to 3.3%
–Boston - 4% to 20%
–Houston - 6% (hot)
–Pittsburgh - 10% (hot)
Running (<21 km) - 1% to 5%
–Falmouth Road Race - <1%
–TC 10 - <1%
Risk of Death in Road Racing
Sudden Cardiac Death
–Estimate 1/100,000 entrants
–MTCM/MCM Cardiac arrest 1:50,000
–Cardiac death 1:220,000 finishers
–Increasing age of entrants
–Over 40 = CAD
–Under 30 = Cardiac anomaly
–Low frequency
Variables & Unknowns
Condition of participants
Prevention Strategies
Public Health Model
Primary Prevention Strategies
–Prevent occurrence of casualties
–Reduce severity of casualties
Does not require cooperation
Requires cooperation or behavior
–Enforced Active
Secondary Prevention Strategies
–Early detection of injury or illness
–Intervention protocols to stop progression
–Impaired runner policy
–Medical intervention protocols
Tertiary Prevention Strategies
–Treatment of illness or injury
–Rehabilitation of illness or injury
–Emergency room transfer
–Hospital admission
–Rehabilitation center
Race Preparation Areas
Competitor safety
Hazardous conditions
Competitor education
Impaired competitor
Race scheduling
Start time
ER notification
Course setup
Fluids & fuel
Medical & race records
Medical protocols
Medical precautions
Adverse event protocol
Competitor safety
Athletes' safety first
Sponsor & TV conflicts
IAAF Temp Rule
Hazardous conditions
Normal prudent behavior
–Suspended by athletes in competition
Raise risk beyond inherent risk of activity
Environment hazards
Does the "event" supercede the safety of
the competitors?
–If you start the race
Runners assume you think it is safe
for them
–What is the duty of the race
administration to protect the runners in
adverse conditions?
Hazardous conditions
Publish protocol in advance
Announce risks at start
Volunteer safety
Threats to Runner Safety
–Hear it, clear it
–30:30 rule
30 seconds
30 minutes
Heat & humidity
Unexpected increases
Lack of acclimatization
Excess fluid consumption
Event Modification Guidelines
WBGT = 0.7 wb + 0.2 bg + 0.1 db
Military Guide
Youth Soccer
>90 F
>82 F
>82 or Alt
>88 F
(<12 wks)
>85 F
(<3 wks HA)
>78 F
Normal risk
>73 F
>73 F - Free
>73 F - Shorten
>65 F
>65 F - Quarter
breaks, Fluids
<65 F
<65 F
Temperature - Humidity Graph
Exertional Heat Stroke Risk
Cold & wet conditions
Increase hypothermia
–Especially slower runners
Inadequate metabolic heat
Race Cancellation
Environment hazards
Threat of terror
Terrorist threats
Establish policy in advance
Enlist local authorities for advice
Integrate into local security plans
Liability considerations
Lawsuits in football
Lawsuits in road racing
–Wrongful death
Is cancellation really that bad...
If it saves a life or decreases
Family test
–What would you want if your child
was entered?
Competitor Education
Safety measures
Risks of participation
Fitness requirements
–Hyponatremia risk
Finish(ing) strategies
Volunteer identification
–Red color shirts
Race Scheduling
Race day
–Most important event decision for a given
–Starting temp >55-60 0F doubles risk
TCM, Boston, Grandma's
Season weather statistics
–Average high temperature = 61 0F
–Average low temperature = 41 0F
–Average relative humidity = 60%
Start Time
Safest start & finish times
Wheelers before runners
Sunrise start
–Noon start, same temp range
Double injury rate
Impact of multiple races
Course closure
Define in race entry form
TCM limits
–13 min, 40 sec / mile pace
–6 hour time limit for marathon distance
Enforce or not?
Impaired competitor policy
No disqualification for medical evaluation
Criteria to proceed
–Oriented to person, place, & time
–Straight line progress toward finish
–Good competitive posture
–Clinically fit appearance
Publish in advance
ER Notification
Hospitals near course
–Date & time
–Course closure
–Injury evacuation plan
–Expected casualties
Preparticipation Screening
Not required in most race settings
Not practical for large field races
Not cost effective
–Small "extreme" events
Pre-sceening questionaires
Medical information on back of race bib
Pre-screening Questions
Entry Form
Are you adequately trained?
Have you had chest pain, rapid heart beat,
or undo breathlessness?
Have you fainted or passed out during
Are you taking medications or supplements
that affect exercise?
Do you have a family history of sudden
Do you understand what the race
Race Bib for Medical Information
Print all bibs with a “back side”
–Name, age, & date of birth
–Emergency contact with phone
–Known medical problems
–Medications & supplements with
–Physical limitations (ie; deafness)
2001 TCM Course Map
Course Setup
Course survey
–Hills, turns, & immovable objects
Boston WC start
–Traffic control
Red Neon
–Altitude changes
Pike's Peak Marathon
–Open water
Chicago Lakefront
4th Street
HHH Metrodome
Chip timing
–Clear starting line
6-7 minutes
Chip technology: Modifications &
benefits to medical plan
"Slows" start
Track competitors
Less early "chute" collapse
–Move collapse site downstream
–Decrease collapse
Chip removal
–Assisted removal avoids delays
Tracking medical casualties
Course Aid Stations
Full medical care
–Finish line
–High risk course marks
Comfort care
–First aid
"the speed of the pit crew
often determines the
outcome of the race"
Aid Station Locations
–Every 2 to 2.5 miles
–Every mile in very large field races
Consider impact on hyponatremia
–First responders
1/4, 1/2, & mile marks
Rolling Aid at ‘96 Olympics
Medical equipped van
First response teams
–Motorcycles or bikes
–Automatic defibrillators
–First aid equipped
EMT trained runners
Course Closure
Trailing vehicle
–"Official" end of race
13 min per mile pace
–Chip start lag
Finish Area Layout
Medical location
Ambulance access
Runner flow
Fluid access
Ambulance support
Well finisher shelter
Dry clothes shuttle
Finish area map
–Chute triage
Watch for WC's
–Post-chute triage
–Area triage
Sweep teams
–Bus drop
–Family info/waiting
Finish Area - Boston
Finish Area
Field hospital
–Major aid station
Intensive medical
Intensive trauma
Minor medical
Minor trauma
Medical records
Well drop-outs on course
Prevent new or increased previous injury
–Stress fracture
TCM protocol
–Mobile on course pick up vans
Sweep between aid stations
–Buses at medical aid stations
Aid station drop-outs
Pick up van drop -drop-offs
Ill or injured competitors on course
Prevent progression of illness or injury
Access care for illness or injury
–Runner location
TCM protocol
–Mobile ALS Ambulance for transports
–Stationary BLS community ambulance
Aid stations
Shelter for ill runners
Transfer to mobile ALS Ambulance
TCM finish area transportation
–Access care in finish area
–TCM protocol
Manned carries
Assisted walk
–Access tertiary care
Portable cellular or digital
Hard wire
–Hand held radios
–Ham radio network
Aid stations
Pick-up vans
Course spotters
–Any volunteer
–Summon ambulance
Course site line contact
–Blanket course with cell phone equipped
Each can see next in line
–Central cell phone number
Where are you?
–42nd & Minnehaha
Finish area
–Central dispatch for course
–Field hospital
–Triage teams
Hand held radios
Fluids & Fuel
Individualize intake recommendations
Risk of too much
–Carbohydrate-electrolyte solutions
> 45 minutes beats H2O
–High carbohydrate foods
Fluids & Fuel
–Aid stations
–Finish area
Post-chute area
Medical tent
Fluids & Fuel
Amount available per runner
–6-12 ounces every 20 minutes
Available vs consumed
–Double for start & finish
–Athletes' preference
–Sponsors' stock
Fluids & Fuel
Publish in advance
–Fluid types
–Food types
Security fencing
Cots, chairs, tables
Heating & cooling
Back boards
Portable sink
Ice chest
IV fluids
–First liter - D5%NS
–Second liter - NS
Medical Operations Budget
–Professional time
–Glucose monitor
–Sodium analysers
–Ambulance time
–Special equipment
How many ... need to be on hand?
MD's, RN's, paramedics, vehicles, radios
Staff & equip for peak of medical activity
–Better to over-estimate
Each race will have a different profile
–Tailor to event needs with race history
Staff:runner Ratios
Worst case number of expected
encounters for condensed time window
Encounters vary with
Rise with heat & humidity
Rise with cold rain
–Start time
–Distance of race
–Condition of participants
–Course profile
–Acute care nurses
–Physical Therapists
–Athletic Trainers
–First aid personnel
Course aid stations
First responder stations on course
–First aid
Mile, 1/2, &1/4 mile marks
Not associated with medical aid
–National Ski Patrol (EMT's)
Mobile response teams
–Civil Bicycle Patrol (EMT's)
Finish area
Base on peak injury rate
Base on injury type
Critical care
Levels of Care for Road Races
National Sports Medicine Institute of
First aid leader
–Ability to contact EMS
No defibrillator on site
Paramedics or physicians or nurses
Ambulance coverage
Treatment centers on site
Defibrillator on site
Communication control center
Plus Bronze
Medical Director
IV capability
Onsite lab analysis
Plus Bronze & Silver
Notify runners in race entry
Based on available care
–Bronze, silver, or gold
–Decide on race entry
Sharing Race Data
Evidence based staffing ratios
–Develop based on race data
–Base on environment
–Accumulated race injury data
Individual race data
National registry
Medical & Race Records
Document care
Calculate incidence of casualties
Project future needs
Entrants, starters, finishers, gender
Document environmental conditions
TCM Medical Record
Medical Precautions
Body fluid precautions
–Blood, stool, vomit, urine
–Not sweat
–Hepatitis B
Modified universal precautions
–Gloves, ? gowns, ? goggles
Medical waste disposal
–Sharps boxes
Medical Protocols
First aid
–Do no harm
–Stay within training level
Collapse Site
Before finish line
Bad sign
–Essential organ system not functioning
Usual problems
–Heat stroke
–Cardiac arrest
–Insulin shock
Collapse Site
After the finish line
Better sign
–Muscle pump is gone
–Vasovagal orthostatic syncope
Usual problem
Medical Protocols
Exercise Associated Collapse
–TCM modifications
D50%W - substrate depleted
Hi dose epinephrine (5-10 mg)
Na bicarbonate - acidosis
Automatic transfer criteria
Medical Protocols
Transfer criteria
–Off course
Send to ER
–Finish line to ER
Cardiac chest pain
Temp > 106 0F
Temp < 94 0F
Blunt trauma
Not responding to Rx
Access to Downed Runners
Finding & Assessing Down
Mobile medical teams
Course marshals & medical spotters
Runners on course
–“Buddy” system
–“Runners helping runners” policy
Comp entry into next years event
Runners who assist a runner in peril
–In the way?
Exit routes from course to
medical care
Urban vs rural vs wilderness access
Ideal entry & exit in direction of runner flow
How long to get to a fallen runner
in worst case?
–4 minutes to CPR
–8 minutes to defibrillation
10% per minute
–Many confounding variables
–Urban vs rural
–Crowd density and cooperation
–Location identity
–Successful resuscitation rate <50%
What is our responsibility to runners?
Runners safer
–Race course vs training run
Runners may be at more risk during a race
Outcome may not always be favorable
Response plan is key to race relations
Managing Catastrophic Outcomes
Information release policy
Talk to family
Chain of command
The spin on death in road racing
–Not every cardiac arrest will be
Goal is rapid response
Reality is locating in crowd
–Better chance of survival
Road race vs training
Adverse Event Protocol
Notify Medical Director
Do not discuss
Controlled press release
Family Information &
How to communicate
–A medical emergency with a runner
Family & friends
Coaches & agents
Considerations & Constraints
Family waiting area
Separate from medical area
Communications with medical area
–Update medical condition
–Locating lost runners
Access to family for health information
Family not in medical area
–Blood borne pathogens
Caring for the Caretakers
• Grief reaction among the race staff
– Medical
– Non medical
– Runners
• Post incident counseling
– Accept & grow
– Cannot purge memory
– Avoid risky coping mechanisms
• Attending the visitation
Post-race Review
What went right?
–Most everything
What went wrong?
Proposed changes
–Make it better
New Medical Developments
Collapsed athlete differential
Cardiac arrest
Exertional heat stroke
–May present with muscle cramping
–May be asymptomatic for several hours
Moderate to severe EAC
–Diagnosis of exclusion
–Resolves with support & time
–Leg elevation
Types available
–Automatic defibrillators (AED)
–Manual defibrillators
–On site
–On course
AED’s on bikes expand range of care
Marathon & longer races
3 deaths past 18 months
–2 confirmed; 1 suspected
–Water excess & dilution
Increased in "hot" conditions
–Can be fatal
–Often associated with seizure
Hyponatremia & Fluid
–Too much fluid intake
–Excess salt losses
Water or hypotonic replacement
Problem in longer races (>4 hrs)
–Unlikely in shorter distance races
–Female athletes 9:1
Parallels rise in charity running & slower
average times
More common in Ironman Triathlons
Key history
Finish time > 4 1/2 hours
–Slow pace
–Long duration activity with lower intensity
High fluid intake
–Mostly water
–"2 full glasses at every water stop"
Not 2 "swallows"
Hot & humid conditions
Key history
Not acclimatized to current temp & RH
Weight changes
–Expect drop in weight
Glycogen utilization & depletion
Mild dehydration for "normal" finisher
–Key weight is training weight
Not pre-race weight
Pre-race weight includes
Glycogen loading & associated water
Symptoms /Signs
–Muscle cramps
–BP, HR, RR normal
–"Impending doom"
–Ashen, gray
–Prolonged seizure
Hyponatremia Solutions
Education runners
–Replace sweat losses
–Forget "drink as much as you can"
Decrease water stops to every 3 K
–Break down extra large field stops at 4
hour plus pace
"Myth" information
–Sports drinks do not prevent
Educate volunteers
Measure Na+ on site
Dehydration during marathon races occurs
–Rarely "severe"
–More common than exertional
–Life threatening rate similar to exertional
Slow competitors
–Limit fluid intake & add salt to fluids
Salty sweaters use salted fluids & salt food
Pre-race, race, & post -race
hydration recommendations
Current ACSM recommendation
–"Replace what you need"
–Replace sweat losses
Race practice has been "One size fits all"
–6-12 oz each competitor every 15-20 min
–Ignores individual differences
Sweat rate
Intensity of exercise
Individualized Fluid Intake
Calculate fluid needs
–For anticipated race pace & conditions
Pre- & post-run weights
–Nude body weight
–½ hour run
Race pace
Anticipated race conditions
–Towel off & re-weigh nude
–Fluid required / hr = weight difference
(oz) x 2
Race Specific Recommendations
By distance
–< 20 K think of heat stoke
–20-50 K think of exhaustion & exercise
associated collapse
–> 50 K think of hyponatremia
–All think cardiac arrest
By size
–Very large races fluid stations
–Risk of too much fluid intake
Race Specific Recommendations
By environment
–Hot, humid
–High altitude
Audit your race
Emergency care
What if...?
–Its too hot
–Its too cold
–Someone dies
–A car crashes the course
Think runner safety
Thank you!
[email protected]

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