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

• 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  Required behavior change

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 Cancel Curtail Extreme caution Military Guide >90 F >88 F (<12 wks) >85 F (<3 wks HA) ACSM Road Race >82 F >73 F Youth Soccer >82 or Alt schedule >73 F - Free substitution >73 F - Shorten games Caution Normal risk >78 F >65 F <65 F >65 F - Quarter breaks, Fluids <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 –Hats

Race Scheduling

 Race day –Most important event decision for a given location –Starting temp >55-60

0

F doubles risk  TCM, Boston, Grandma's  Season weather statistics –Average high temperature = 61

0

F –Average low temperature = 41

0

F –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 environment could be on race day?

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) –Allergies

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

Start

 HHH Metrodome –Shelter  Chip timing –Clear starting line  6-7 minutes  Types –Mass –Wave –Split 4th Street 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 H

2

O –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 - D

5%

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 –Finish push

 Personnel –Physicians –Acute care nurses  ICU  CCU  ER –Paramedics –EMT's

Staffing

–Physical Therapists –Athletic Trainers –First aid personnel –Non-medical assistants

 Location –Start –Course –Finish

Staffing

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) –EMS Paramedic Bike Teams

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 –Red bag waste

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

0

F  Temp < 94

0

F  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 –Death rate in marathon is 1 in 100,000

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

 Early –Lightheaded –Dizzy –Nausea –Headache  Severe  Progressive  Middle –Vomiting –"Puffy"

Symptoms /Signs

–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

 Educate volunteers prevent  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!

[email protected]