Transcript The SC Half Ironman A view from the Medical Tent

The SC Half Ironman:
A View from the Medical
Tent
Dave Sealy, MD
Clinical Professor, AHEC, Greenwood
Director, Self Regional Healthcare, PCSM Sports Medicine
Fellowship
Head Team Physician, Lander University
SC Half Ironman: A view from the
medical tent
SC Half Ironman: A view from the
medical tent
SC Half Ironman: A view from the
medical tent
• Character and History of
Triathlon
• What about Triathletes?
• SC Half Triathlon
• What to prepare for in
the tent
– Swim
– Bike
– Run
• How to prepare/logistics
• For the aspiring race
directors
SC Half Ironman: A view from the
medical tent
History of Triathlon
• Started in 1974 - San Diego, CA
• 1978 Navy Commander John Collins….
– Which sport requires greater endurance?
– Inaugural “Ironman” Event combined:
• Waikiki Rough Water Swim
• Oahu Road Race
• Honolulu Marathon
2.4 miles
112 miles
26.2 miles
• Winning Time 1978
11:46.58
History of Triathlon
• Moved to Kona, Hawaii
in 1981
• Hotter, drier, much less
traffic
• Hawaii record: 8:08,
Men’s world record: 7:52
• Approx 30 Ironman
length races in US in
2010
History of Triathlon
• Currently
– >300 races per year in the
US
– Best triathletes in world
currently Australian
– Excellent sport for aging
athletes
• Multiple sports reduces overuse
injuries
• Enables developing skills at
three aerobic sports
• Allows for team competition
• Has age group competition into
the 80s!
Governing Bodies
• International Triathlon Union (ITU)
• USA Triathlon (USAT)
• Both have published standards for medical
coverage of triathlon events
• Lengths of races
Swim
Ride
Run
Sprint
750m
20km
5km
Olympic
(standard)
1.5km
40km
10km
Long Course
1.9km
90km
21.1km
Ultra/Ironman
3.8km
180km
42.2km
Visits to Medical Tent
Interesting Facts
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Sprint
Standard
Long course
Ultra
1% racers
2%
11%
19-24%
1:10 (0:50)
2:45 (1:42)
5:45 (3:47)
12:30 (7:52)
Triathlon Effects on Athletes
• Cardiac
– 85% athletes day of
Ironman  elevated
cTnT
– 16% in diagnostic
range for injury/infarct
– 24% elevated day
post and 5.5% c/w
injury
– Those with injury level
cTnT had reduced
global LVF and stroke
volume
Tulloh, Robinson, Patel, Ware et al .Raised cTnT and
echocardiographic abnormalities after prolonged strenuous
exercise. Br Jl Sports Med 2006;40:605-609
Triathlon Effects on Athletes
• Caloric utilization of 850012,000 kcal/Ironman
• 3% loss in body mass during
the race
• 1-2 liter/hour average sweat
loss over 12 hours
• No significant change in Na,
K, Cl
• Urine SG > 1.011-1.017
• 1.1 degree C rise in core
Temp in first 1.5 hours, no
change thereafter
Laursen, Suriano, Quod et al. Core temperature and hydration status during an
Ironman triathlon. Br J Sports Med 2006:320-325.
Triathlon Effects on Athletes:
Injuries
• Vast majority of injuries are
overuse (98%)
• Olympic Distance vs Ironman
Distance training did not
differentiate in overall injury rate
• OD injury rates were higher for
Achilles, ankle and gastroc injuries
• IM distance higher for back, knee
and hamstring injuries
• Injury in one discipline leads to
overuse injury in others (swim,
bike, run)
• Competitive running experience
associated with decreased injury
rate
Vleck, Bentley, Millet, Cochrane. Jl Strength Cond Rsch. Triathlon Event
distance specialization: training and injury effects: 24(1):30-36
Triathlon: What about age?
• Excellent sport for
aging endurance
athletes
• Excellent sport for
reborn athletes
• Fewer overuse
injuries than
running in older
Triathlon: What about age?
• Performance improves slightly until age 3539 in males and 30-34 in females
• Slight drop in performance after these ages
• Steeper drop-off after 50-54 age group in all
three disciplines
• More rapid for ID versus OD
• More rapid for swimming and running than
biking performance
Lepers, Sultana et al. Age-related changes in triathlon performances. Int J Sports Med 2010; 31: 251-256
SC Half Triathlon
• 1.2 mile swim, 56 mile
bike, 13.1 mi run (Half
Ironman length)
• Started 2003 (Ninth this
year)
• Approx 170-650
participants
• Average temp at start: air
74, WBGT 73, water 76
degree (last year 85)
• Average temp at finish: air
91, WBGT 94!!
SC Half Triathlon
• Over 100 volunteers
• At Greenwood State
Park
• Preparation begins over
one year ahead
• Chamber of Commerce
Event
• Start time 0730
• Cost now $175
individual, $280 team
• Horseshoe shaped
swim, loop rolling bike,
flat run
SC Half Triathlon
• Medical Tent
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30 x 60 feet size
Four large fans
6 folding chairs
24 cots, 24 pillows, 100 towels,
sheets, blankets all donated by
Self Regional
– 6-8 physicians, 3 ER nurses, 4
paramedics, 1 lab tech, 3-4
others to weigh, assist and enter
data
– 50 one liter bags NS
– 5 100ml bags 3% NS (hot salt)
SC Half Triathlon
• Medical Tent
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Data entry
Self care area
Restricted access
Scale to weigh arriving
athletes
200 liters of HOH,
electrolyte drinks
Ice bath of towels
3 Ambulances with AEDs
Meet 10 AM for briefing
Tent Organization
• Finish line triage
(90% of all visits)
• Check in/data
entry
• MD/ER nurse
evaluation
• iSTAT labs drawn
• Treatment
• Discharge
Common Triathlon
Injuries/Illnesses
• Swim
– Hypothermia
– Abrasions, lacerations,
contusions
– Corneal/Eye injury
– Near drowning/aspiration
– Exit injuries
– Panic/anxiety
Swim-Eye Injuries
• Diagnosis
– Goggles
– Corneal abrasions
– Chemical irritation
• Treatment
– Quick visual acuity
– Saline eye rinse
– Ophthalmic drops
Swim-Near Drowning
• Causes
– Head injury
– Rough and wild starts
– Weather changes
• Rough conditions in shallow
water
• Treatment / Prevention
– Adequate training
– Rescue persons
• Boats
• Boards
• Divers
– Check conditions
– Head counts in and out
– Captains for all courses
Common Triathlon
Injuries/Illnesses
• Bike
– Trauma most common:
falls or collisions
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Road rash very common
Fractures common
Head injury
May have to disqualify
athlete with head injury or
suspected fracture
Common Triathlon
Injuries/Illnesses
• Treatment
– Prevention: all US
races require helmets
– Clean road rash gently,
may irrigate with saline
– Cover with non
adherent dressing, ?
benefit of antibiotics
– Stabilize fractures and
transport if necessary
– Look for injury under
the road rash
Common Triathlon
Injuries/Illnesses
• Run
– >80% all injuries/illnesses occur at finish line
– Exercise associated collapse
– Hyponatremia
– Hyperthermia
– Hypovolemia
– Muscle cramps
– GI issues
– Sunburn
Common Triathlon
Injuries/Illnesses
• Exercise Associated
Collapse
– Common with marathons,
triathlons
– May occur in races under
one mile
– Usually occurs at finish line
– Related to transient postural
hypotension
– Walk through finish area
– Elevate feet
– Consider hypovolemia,
hyperthermia, cardiac issues
Common Triathlon
Injuries/Illnesses
• Hyponatremia
– More common in
women/less conditioned
– Races longer than four
hours
– Overhydration during the
race increases risk
– Racer presents with GI
distress, mental status
changes, confusion,
seizures
– Needs to be treated as an
emergency if <130
– hypertonic saline (3%NS)
per our protocol
Common Triathlon
Injuries/Illnesses
• Dehydration/Hyperthermia
– Measure core temp
– Weigh if possible
– If over 104 degrees, treat as
emergency
– Higher risk for rhabdomyolysis
– May have altered mental status,
seizures
– Treat with rapid cooling, ice water
immersion, IV fluids per protocol
– Rehydrate with iced NS and transport
– Better to rehydrate orally, better
absorbed
Common Triathlon
Injuries/Illnesses
• Muscle/heat cramps
– May be due to electrolytes or
injury
– Rehydrate orally if possible
and IV if necessary
– Massage
– Diazepam
– Consider Mag SO4 2-4 gm IV
– May need to be carried
Run-Cardiac
• Diagnosis
– Increased concern in
collapse occurring before
finish
• Treatment
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Rapid assessment
CPR
Early Defibrillation
PRACTICE
Common Triathlon
Injuries/Illnesses
• Other finish line
concerns
– Blisters
– Insect bites/stings
– Sunburn
– Allergic reactions/
anaphylaxis
Common Triathlon
Injuries/Illnesses
• In eight years we have
seen….
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VT with hypotension
Fractured clavicle
Paralytic cramping
Mental status changes
Concussion
Severe AC separation
LOTS of dehydration/post
race collapse
Volunteers
• USAT recs*
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1 doc / 500-1000 athletes
1 nurse / EMT per 500 athletes
“Adequate” Massage personnel
Finish line triage 1 CPR trained /
200-300 athletes
– 2 ambulances at least (1 at finish
line)
• ITU recs:
– 1 doc/200 athletes (4 minimum)
– 1 nurse/100 athletes (6 minimum)
– 3 ambulances per 1000 athletes
Volunteers
• Team approach
– Physicians, Nurses, Paramedics, Residents,
Chiropractic, Massage Therapists
Volunteers
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Race Director: usually paid
Police and other authorities
Course monitors
Volunteers to hand out food/fluids
Recognition needs to be given to sponsors
Tremendous amount of organization
Coordinate lake, ocean and road traffic
Participants
• Number of people
– Supplies commensurate with numbers
– Medical forms on all kept in Medical tent
– All are weighed at start and written on bib
• Review the pre-participation form
– Meds, Allergies
– Medical problems
• How will the info be accessible?
– Computer- we use Excel spread sheet
– Paper: every athlete fills out medical summary
Supplies
Supply
Have
NeedResponsibilit
Loc at
y ion
Medical Equipment
AED
0
1ambulanc
am
e bulanc e
Bac kboard
0
1ambulanc
am
e bulanc e
Biohazard bags
100 100
BioHazard box
BP c uffs
0>3
MDs, RNs, MS
Cervic al c ollars
0
1ambulanc
am
e bulanc e
Crash c art
0
1ambulanc
am
e bulanc e
Flashlight s or penlight
0>2
MDs, RNs, MS
Int ubat ion kit
0
1ambulanc
am
e bulanc e
Ot o- ophthalmosc ope
0>1
MD t o bring
Sharky (t ape c ut t er)
0??
?? AT Cs??
Sharps c ont ainers
3
31 small in Ppbox; 2 lg in M
St et hesc ope
0>3
MDs, RNs, MS
T hermomet er (rec tal)
0
2
ric h
T hermomet er sheat hs
0?50
ric h
T ournaquet s
1 roll
1 roll
BG (side) and GG t
Supplies: alphabetical
Medical Supplies
Ace Wraps 3"
Ace wraps 4"
Alcohol wipes
Angiocaths 18 gauge
Angiocaths 20 gauge
Arm Slings
BandAids, sheer
Bandage, conforming
Bandage, liquid skin crack
Bandage, liquid spray
Benzoin tincture
Bioocclusive dressing
Blankets, yellow EMS
Blankets, mylar
Body powder/Gold Bond
Contact lens case
Drapes, blue. Non-sterile
Eye Pads
Eye wash
Flourecein strips
Forceps
Gauze bandage roll
Gauze pads 2x2
Gauze pads 4x4
Gloves, disposable
Gloves, latex-free (S, M, L, XL)
Gloves, sterile
Heel wedges
Hydrogen peroxide
Isopropyl alcohol
IV tubing (ADULT),
Kerlex
Metatarsal pad
Molefoam padding
Nail clipper/filer/tweezer set
Supplies: alphabetical
Needles 18G
Needles 20G
Needles 21G
Needles 22G
Needles 23G
Needles 25G
Needles 30G
Needles IV by 1.5
Needles FILL by 1.5
Petroleum jelly
Povidone iodine sol'n
Qtips, sterile
Safety pins
Saline irrigation 0.9% 0.5 L
Saline irrigation 0.9% 1L
Saran wrap delivery system
Scalpel
Scissors, bandage
Scrub brushes, sterile
Sheets, white 40x90 disposable
Splint, finger w/ aluminum foam
Splint, forearm
Stapler, pre-loaded
Staple remover
Spray bottles
Sterile field
Steri-strips 1.25"
Sunscreen 30spf, spray on
Suture kit
Suture removal kit
Sutures 4.0 Vicryl
Sutures 4.0 Ethilon
Syringes 3cc
Syringes 6cc
Syringes 12cc
Syringes 20cc
Syringes 60cc
Supplies: alphabetical
Ta m pons
T a pe , tra n sp o re
T a pe , 2" p a pe r
T a pe , 1" clo th
T e ga d e rm d re s sin g
T e lfa pa d s , n o n -stick
T o ng u e Bla d e s
Xe ro fo rm d re s s in g
U rin a l, fe m a le
U rin a l, m a le
Zip lo ck b a gs
Supplies: by type
Prescription Meds
0 .9 % N aC l D 5 ?
A lbuterol inhaler
A lbuterol s pac er
D extros e 5 0 ampules
D iazepam injec tions
D imenhydrinate 5 mL (dramamine)
D iphenhydramine 5 0 mg/1 mL (Benadryl)
E pinephrine 1 :1 0 0 0 mL
L idoc aine 1 % no epi.
L idoc aine 2 % vis c ous
M agnes ium s ulfate ampules
T etrac aine topic al anes thetic
T ropic amide c yc loplegic
OTC Meds
Acetominophen/tylenol
Aspirin 325mg, enteric coated
Bacitracin individual packets
Bacitracin ointment
Bactine pain reliiever antiseptic spray
Bismuth sulfate/Peptobismal
Blister kits
Ca Carbonate antacid 500mg
Cough drops, cherry
Famotidine/Pepcid 10mg
Hydrocortisone 1% w/aloe
Ibuprofen
Loratadine antihistamine
Neosporin triple antibiotic oint.
Oxymetazolone nasal decongest
Pseudoephedrine 30mg
Salt tabs
Supplies: by type
IV Starter Equipment
Eye care
0.9% NaCl 500 mL
Blac k light
0.9% NaCl D5?
Contac t lens c ase
*
Angiocaths 18 gauge
Eye Pads
Angiocaths 20 gauge
Eye wash
Caddy for carrying equip
Flourec ein strips
Clothesline and S hooks for IV hangers
Coban wraps 2"
Tet rac aine topic al anesthetic
Tropic amide c yc loplegic IV tubing (ADULT)
Needles 18G
Needles 20G
Foot care
Needles 21G
Bac it rac in individual pac ket s
Needles 22G
Blist er kit s (bandaid, 2x2, bac it rac in)
Needles 23G
Donut c ut out s, premade
Needles 25G
Heel wedges
Needles 30G
Met at arsal pad
Needles IV by 1.5
Molefoam padding
Needles FILL by 1.5
Tournaquets
Nail c lipper/filer/t weezer
set
Supplies: by type
Wound care
Ace Wraps 3"
Ace wraps 4"
Arm Slings
BandAids, sheer
Bandage, conforming
Bandage, liquid skin crack
Bandage, liquid spray
Benzoin tincture
Drapes, blue. Non-sterile
Dressing, Bioocclusive
Dressing, Tegaderm
Dressing, Xeroform
Forceps
Gauze pads 2x2
Gauze pads 4x4
Gloves, disposable
Gloves, latex-free (S, M, L, XL)
Gloves, sterile
Hydrogen peroxide
Isopropyl alcohol
Kerlex
Povidone iodine sol'n
Q tips , s terile
S aline irriga tion 0 .9 % 1 L
S c alpel
S c rub brus hes , s terile
S tapler, pre - loaded
S taple remover
S terile field
S teri- s trips 1 .2 5 "
S uture kit
S uture removal kit
S utures 4 .0 V ic ryl
S utures 4 .0 E thilon
S yringes 3 c c
S yringes 6 c c
S yringes 1 2 c c
S yringes 2 0 c c
S yringes 6 0 c c
Supplies: by type
Wound care
Ace Wraps 3"
Ace wraps 4"
Arm Slings
BandAids, sheer
Bandage, conforming
Bandage, liquid skin crack
Bandage, liquid spray
Benzoin tincture
Drapes, blue. Non-sterile
Dressing, Bioocclusive
Dressing, Tegaderm
Dressing, Xeroform
Forceps
Gauze pads 2x2
Gauze pads 4x4
Gloves, disposable
Gloves, latex-free (S, M, L, XL)
Gloves, sterile
Hydrogen peroxide
Isopropyl alcohol
Kerlex
Povidone iodine sol'n
Q tips , s terile
S aline irriga tion 0 .9 % 1 L
S c alpel
S c rub brus hes , s terile
S tapler, pre - loaded
S taple remover
S terile field
S teri- s trips 1 .2 5 "
S uture kit
S uture removal kit
S utures 4 .0 V ic ryl
S utures 4 .0 E thilon
S yringes 3 c c
S yringes 6 c c
S yringes 1 2 c c
S yringes 2 0 c c
S yringes 6 0 c c
Supplies: ITU recs
1. Bandage and splint materials to care for 5% of competitors
2. Medication for acute cardiac care. All physicians and nurses must be
familiar with supplies and their operation.
3. Suture materials and emergency surgical supplies
4. Rectal thermometers: Electronic rectal and tympani thermometers
(one per nurse)
5. Two EKG/Defibrillators will be available and tested
6. Blankets and towels will be adequate to care for 15% of competitors
7. One liter of water per 5 athletes, plus whatever other fluids the RMD
chooses
8. Intravenous fluid set-ups for 10% of race competitors, with one liter
of fluid per set-up. Recommended fluid for Olympic distance
competitions is 5% dextrose, 1/2 normal saline solution or a similar
solution
9. One kilogram of ice for every four competitors
10. Three large tables
Supplies: USAT recs
1. Equipment for cardiovascular emergencies (defibrillator, cardiac and
respiratory drugs, oxygen, airways) for use if ambulance is in
transport.
2. Thermometer: electric, rectal and/or tympanic- 1 per treatment
area/team
3. Blood pressure cuff and stethoscope 1 per treatment area/team
4. Blankets and towels for 15% of competitors
5. Bandage/splint/dressing material for 5% of competitors
6. Oral fluids: 1 L per 5 athletes
7. Ice: 1 kg per 4 participants
8. IV fluids for 10% of the competitors (1 L per setup). D5 1/2 normal
for Olympic distance events (NS for longer events). This includes
tape and gauze (and approved sharps containers)
9. Latex gloves/ handwashing supplies for all personnel
10. Disposable bags for bloodborne pathogens
11. Tables 3-5 six feet in length
Volunteers
• You meet some
interesting and
inspiring people
• And some unsavory
types as well!
• Contact me:
dsealy@selfregional.
org
Thanks
• To Aaron Rubin,
MD PCSM
• Jamie Sabin,
MD PCSM
– Fellow race
directors