Medical Planning &
Management
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
School
Objectives
• 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
Liability
Runner catastrophe
Where to Put Your Money
•
•
•
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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
Pre-race
–Improve competitor safety
–Prevent excess injury & illness
Race day - Primary
–Stop progression of injury or illness
Triage
Treatment
Transfer
Race day - Secondary
–Prevent emergency room overload
Race Medical Operations Purpose
Post-race
–Make it better
Planned Disaster
Mass gathering
–Potential for
casualties
Primary goal of medical
team
–Safety of competitors
Attention to details
–Improves safety
profile
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
Hyponatremia
–Low frequency
Risk
Variables & Unknowns
Weather
Condition of participants
Ankle-biters
Prevention Strategies
Public Health Model
Primary
Secondary
Tertiary
Primary Prevention Strategies
Definition
–Prevent occurrence of casualties
–Reduce severity of casualties
Types
–Passive
Does not require cooperation
–Active
Requires cooperation or behavior
change
–Enforced Active
Secondary Prevention Strategies
Definition
–Early detection of injury or illness
–Intervention protocols to stop progression
Examples
–Impaired runner policy
–Medical intervention protocols
ACLS
ATLS
EAC
Tertiary Prevention Strategies
Definition
–Treatment of illness or injury
–Rehabilitation of illness or injury
Examples
–Emergency room transfer
–Hospital admission
–Rehabilitation center
Race Preparation Areas
Competitor safety
Preparticipation
screening
Hazardous conditions
Competitor education
Impaired competitor
policy
Race scheduling
Start time
ER notification
Course setup
Communications
Transportation
Fluids & fuel
Equipment
Supplies
Staffing
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
–Heat
–Cold
–Traction
–Wind
–Windchill
–Lightning
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
Alternatives
–Alter
–Postpone
–Cancel
Publish protocol in advance
Announce risks at start
Volunteer safety
Threats to Runner Safety
Lightning
–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
Action
Military Guide
ACSM Road
Race
Youth Soccer
Cancel
>90 F
>82 F
>82 or Alt
schedule
Curtail
Extreme
caution
>88 F
(<12 wks)
>85 F
(<3 wks HA)
Caution
>78 F
Normal risk
>73 F
>73 F - Free
substitution
>73 F - Shorten
games
>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
–Heatstroke
Lawsuits in road racing
–Hyponatremia
–Wrongful death
Is cancellation really that bad...
If it saves a life or decreases
morbidity?
Family test
–What would you want if your child
was entered?
Competitor Education
Safety measures
Risks of participation
Fitness requirements
Hydration
–Hyponatremia risk
Nutrition
Finish(ing) strategies
Volunteer identification
–Red color shirts
–Vests
Race Scheduling
Race day
–Most important event decision for a given
location
–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
–Elite
–Citizen
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
Exception
–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
exercise?
Are you taking medications or supplements
that affect exercise?
Do you have a family history of sudden
death?
Do you understand what the race
Race Bib for Medical Information
Print all bibs with a “back side”
Content
–Name, age, & date of birth
–Emergency contact with phone
number
–Known medical problems
–Medications & supplements with
dose
–Physical limitations (ie; deafness)
2001 TCM Course Map
Start
Finish
Course Setup
Course survey
–Hills, turns, & immovable objects
Boston WC start
–Traffic control
F6
Red Neon
–Altitude changes
Pike's Peak Marathon
–Open water
Chicago Lakefront
4th Street
Start
HHH Metrodome
–Shelter
Chip timing
–Clear starting line
6-7 minutes
Types
–Mass
–Wave
–Split
Start
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
–Fluids
–Shelter
"the speed of the pit crew
often determines the
outcome of the race"
Course
Aid Station Locations
–Every 2 to 2.5 miles
–Every mile in very large field races
>15,000
Consider impact on hyponatremia
–First responders
1/4, 1/2, & mile marks
Rolling Aid at ‘96 Olympics
Medical equipped van
Course
First response teams
–Motorcycles or bikes
–Automatic defibrillators
–First aid equipped
EMT trained runners
–Phone
–CPR
–AED?
Course Closure
Trailing vehicle
–Marked
–"Official" end of race
13 min per mile pace
–Chip start lag
Finish Area Layout
Medical location
Ambulance access
Runner flow
Fluid access
Shelter
Ambulance support
Well finisher shelter
Dry clothes shuttle
Finish area map
Triage
–Chute triage
Watch for WC's
–Post-chute triage
–Area triage
Sweep teams
–Bus drop
–Family info/waiting
tent
Elite
Medical
area
Finish Area - Boston
Finish Area
Field hospital
–Major aid station
–Subdivisions
Triage
Intensive medical
Intensive trauma
Minor medical
Minor trauma
Skin
Medical records
Transportation
Well drop-outs on course
Prevent new or increased previous injury
–Hypothermia
–Stress fracture
–Strain
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
Transportation
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
Transportation
TCM finish area transportation
–Access care in finish area
–TCM protocol
Wheelchair
Manned carries
Assisted walk
–Access tertiary care
Ambulance
ALS
Communications
Type
–Phone
Portable cellular or digital
Hard wire
–Hand held radios
–Ham radio network
Communications
Locations
–Start
–Course
Aid stations
Pick-up vans
Course spotters
Ambulance
Other
911
–Any volunteer
–Summon ambulance
Communications
Course site line contact
–Blanket course with cell phone equipped
volunteers
Each can see next in line
–Central cell phone number
Where are you?
–42nd & Minnehaha
Communications
Finish area
–Central dispatch for course
–Field hospital
Phone
–Triage teams
Hand held radios
Fluids & Fuel
Type
–Water
Individualize intake recommendations
Risk of too much
–Carbohydrate-electrolyte solutions
> 45 minutes beats H2O
–High carbohydrate foods
Fluids & Fuel
Location
–Start
–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
Food
–Athletes' preference
–Sponsors' stock
Fluids & Fuel
Publish in advance
–Fluid types
–Food types
–Locations
Equipment
Shelter
–Tents
–Vehicles
–Buildings
Security fencing
Cots, chairs, tables
Heating & cooling
equipment
Generator
Defibrillator
Tubs
–Rubbermaid
Fans
Back boards
Lights
Portable sink
Toilet
Ice chest
Supplies
Medical
Trauma
IV fluids
–First liter - D5%NS
–Second liter - NS
Medical Operations Budget
Donations
–Professional time
–Supplies
Borrow
–Defibrillators
–Glucose monitor
–Sodium analysers
–Wheelchairs
Rent
–Tents
–Heaters
–Blankets
–Cots
–Tables
–Chairs
Purchase
–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
–Environment
Rise with heat & humidity
Rise with cold rain
–Start time
–Distance of race
–Condition of participants
–Course profile
Staffing
Personnel
–Physicians
–Acute care nurses
ICU
CCU
ER
–Paramedics
–EMT's
–Physical Therapists
–Athletic Trainers
–First aid personnel
–Non-medical
assistants
Staffing
Location
–Start
–Course
–Finish
Staffing
Course aid stations
–Physician
–RN
–EMT
Staffing
First responder stations on course
–First aid
–Locations
Mile, 1/2, &1/4 mile marks
Not associated with medical aid
stations
–National Ski Patrol (EMT's)
Communications
Mobile response teams
–Civil Bicycle Patrol (EMT's)
Staffing
Finish area
–Numbers
Base on peak injury rate
–Qualifications
Base on injury type
–Physicians
FP
ER
Critical care
Levels of Care for Road Races
National Sports Medicine Institute of
UK
–Bronze
–Silver
–Gold
Bronze
First aid leader
–Ability to contact EMS
No defibrillator on site
Silver
Paramedics or physicians or nurses
Ambulance coverage
Treatment centers on site
Defibrillator on site
Communication control center
Plus Bronze
Gold
Medical Director
IV capability
Onsite lab analysis
Plus Bronze & Silver
Notify runners in race entry
materials
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
Research
Entrants, starters, finishers, gender
Document environmental conditions
TCM Medical Record
Medical Precautions
Body fluid precautions
–Blood, stool, vomit, urine
–Not sweat
Risks
–Hepatitis B
–HIV
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
–Hyponatremia
–Rhabdomyolysis
–Insulin shock
–Anaphylaxis
Collapse Site
After the finish line
Better sign
Etiology
–Muscle pump is gone
–Vasovagal orthostatic syncope
–Dehydration
Usual problem
–EAC
Medical Protocols
Exercise Associated Collapse
CPR
ACLS
–TCM modifications
D50%W - substrate depleted
Hi dose epinephrine (5-10 mg)
Na bicarbonate - acidosis
ATLS
Automatic transfer criteria
Medical Protocols
Transfer criteria
–Off course
Send to ER
–Finish line to ER
Cardiac chest pain
Shock
Temp > 106 0F
Temp < 94 0F
Blunt trauma
Not responding to Rx
Access to Downed Runners
Finding & Assessing Down
Runners
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
Spectators
–Spotters?
–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?
Goals
–4 minutes to CPR
–8 minutes to defibrillation
10% per minute
Reality
–Many confounding variables
–Urban vs rural
–Crowd density and cooperation
–Location identity
–Successful resuscitation rate <50%
Expectations
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
resuscitated
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 &
Communication
How to communicate
–A medical emergency with a runner
Family & friends
Coaches & agents
Media
Considerations & Constraints
Ethics
Confidentiality
Consent
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
–Confidentiality
–Privacy
–Blood borne pathogens
–Space
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?
–Identify
Proposed changes
–Make it better
New Medical Developments
Collapsed athlete differential
diagnosis
Cardiac arrest
Exertional heat stroke
Hyponatremia
–May present with muscle cramping
–May be asymptomatic for several hours
Moderate to severe EAC
–Diagnosis of exclusion
–Resolves with support & time
–Leg elevation
Defibrillators
Types available
–Automatic defibrillators (AED)
–Manual defibrillators
Locations
–On site
–On course
AED’s on bikes expand range of care
Hyponatremia
Marathon & longer races
3 deaths past 18 months
–2 confirmed; 1 suspected
–Water excess & dilution
Increased in "hot" conditions
Significance
–Can be fatal
–Often associated with seizure
Hyponatremia & Fluid
Recommendations
Causes
–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
Early
–Lightheaded
–Dizzy
–Nausea
–Headache
Severe
Progressive
Middle
–Vomiting
–"Puffy"
–Muscle cramps
–BP, HR, RR normal
–"Impending doom"
–Dyspnea
–Confusion
Late
–Ashen, gray
appearance
–Prolonged seizure
–Obtundation
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
Prevention
Dehydration during marathon races occurs
–Rarely "severe"
–More common than exertional
hyponatremia
–Life threatening rate similar to exertional
hyponatremia?
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
Acclimatization
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
–Hot
–Cool
–High altitude
Summary
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!
rober037@umn.edu