The thing about medical emergencies is they’re emergencies, which means they can happen anytime and when they do you have to be prepared to respond quickly. And putting on a race means that you know that there are going to be a certain amount of medical emergencies and non-emergencies: minor, moderate, and serious.

Dr. William Roberts, medical director for the Twin Cities Marathon, once called a major marathon a “planned disaster,” by which he means that there is going to be planned overload on the medical staff and it’s simply a question of preparing adequately for the surge. Even small and medium-sized races need to have a plan in place both for the mild medical issues that will likely arise and for the serious ones that could happen.

“Part of the reason we’re there is so they don’t all end up in the ER,” said Roberts, so that you don’t overrun the local medical system.

Many permits for a race will require a medical plan for just this reason.

Staff your medical resources

Most importantly, even small and medium-sized races need to invest in medical staff and resources, said both Roberts and Chris Troyanos, ATC, long-time medical coordinator for the Boston Marathon. You can’t take for granted that nothing serious will happen just because your race is shorter or smaller.

Will you hire EMS or rely on volunteer medical staff? It can be challenging right now to find physicians who want to work events and take on that liability, said Troyanos. You need to have someone who at least knows CPR and can use an AED, said Roberts. You also shouldn’t be putting the race director in the position to make medicals diagnoses of athletes; you should have some kind of medical director to develop a medical plan. And even if you rely on volunteer medical staff, you’ll likely need to have EMT or paramedics on standby.

When someone hires him to run their medical services, said Troyanos, the first thing he does is reach out to the fire and the police departments, and then talks with the local hospitals so they’re aware. “You have to have some level of coordination,” he said.

The medical plan will then start by figuring out the approximate surge capacity (ie. the largest amount of medical issues you’ll likely have to deal with). A rule of thumb is the peak amount will be 1-2% of field size, though that can be more when the race is longer or hotter. What is considered hot also depends on the seasonal weather—what athletes in the area are accustomed to and how prepared they are (ie. if you have more beginners or more elite athletes, if the race is in Florida or Minnesota). A rough staffing estimation, said Roberts, is up to two medical staff for a 5K, 2-4 staff for a 10K, and 5-10 staff for a half-marathon or longer, for up to every 1,000 athletes—taking into account, of course, weather and conditions.

Prepare for the most common emergencies

Once you have your race medical staff, you need to decide what kind of medical services you will provide on site, said Roberts. Will you be basic first aid or higher level medical care? Again, that depends on weather, history, field size, and athlete demographics. If you’re going to provide things like IVs and ice baths, then that’s a higher level medical tent.

No matter what, you should prepare for the most common medical issues. While most visits to race-day medical are often musculoskeletal—chaffing, blisters, sprains, strains, abrasions and cuts—there are a few serious common issues all races should know about:

–    exercise associated collapse

–    exertion heat stroke

–    exercise associated hypoglycemia

–    anaphylaxis

–    cardiac arrest

Read more about the most common medical issues and how to recognize them.

To deal with these common medical issues, Roberts said even small events should have, at a minimum: an automated external defibrillator (AED), quick epinephrine in case of an allergic reaction, some kind of glucose for diabetics, and at least a basic plan for a way to cool people down. Serious heat stroke can be very intensive to treat, typically involving either ice water tubs (which require a hose hookup), rotating cold ice water towels replaced as they warm up, or a “six-pack of ice” system putting bags of ice in the neck, groins, and armpits.

However, if you want to fully diagnose and treat heat stroke, you also need to take a rectal temperature. And if you want to treat hypoglycemia, you really should have the ability to check sodium levels. “If you don’t have the capacity to check sodium on site, then no reason to have IV/saline,” said Roberts. Taking in salty broth orally is often as good as IV if the athlete isn’t throwing up.

Create a communication & access plan

“I can’t prevent the cardiac arrest, but I can make sure I can respond to it as quickly as hell,” said Troyanos. Cardiac arrest in a race is relatively rare, but when it does happen it’s the most serious medical issue and survival depends on how quickly someone is able to get to the athlete and use an AED (and have emergency ambulance services transport them).

To prepare your medical plan, answer two questions, said Troyanos: How will you respond quickly? How will your medical staff communicate?

In addition to finish line medical tents, you should also have medical staff out on course. Troyanos and Roberts said they’ve both relied more on mobile medical staff in recent races, which allows staff with AEDs to be riding around on bikes with radios and communication tools—and can then respond quickly. The key, however, is having a communication plan in place: either using spotters on course (at multiple points so that if two spotters call in then the responding medical services know the athlete is in between those two points) or using a radio or app system, so that when a call comes in the closest person is immediately dispatched to the incident and 9-1-1 is called first if needed—for example, in the case of a cardiac arrest. Roberts said they’ve also started using a Race Safe app, which allows medical staff to input an athlete’s bib number and get their medical info, track their location, and follow their diagnosis and outtake.

Once you have a staffing plan, a plan for responding to common medical issues, and a communication plan, design your medical area:

–    Look at your course and figure out how ambulances or emergency crew will access athletes. Where will medical responders be stationed? Will they be mobile throughout the course or at certain spots? How will they communicate?

–    Put medical services upstream from the finish, stationing someone about 500-600 yards before the line. It’s “fairly common,” said Troyanos, to have cardiac and other issues at that point. It also allows medical to spot and prepare for athletes.

–    At the finish line, use spotters to identify athletes who might need help. If someone is looking unsteady, then have a conversation with them to check their mental state, said Troyanos. Direct people who need help to the medical tent or medical area.

–    The med tent should be about 40-50 yards from the finish line. At larger races (or races that will require more medical needs because of the heat, length, or extremity of the event), you may need to staff the finish area with people to help transport athletes and intake athletes. Best practices dictate large medical tests should operate using a triage and intake system—much like a mobile ER.

–    And then don’t forget about the post-finish. In larger races, again, you’ll want to have some spotters or staff in the post-finish or food area to spot any athletes who might be having issues. It’s not uncommon for their to be the occasional serious medical reaction well after the finish line—and have a plan on how to get to those athletes, because the density of people at that point can make quick access challenging.

 About the Author

Kelly O’Mara is the former editor-in-chief of Triathlete Magazine and the founder of the Triathlonish

 

by Kelly O’Mara

The finish line and sidelines of a running race can sometimes look a little bit like medical chaos: people throwing up, bent over, some laying on the ground or stumbling around. Of course, the vast majority of those athletes don’t end up in the medical tent, they’re just tired or overexerted.

But, some of the runners do need medical help and a small number will need very serious medical assistance. Every race director needs to be prepared with a medical plan and an awareness of the most common medical issues.

As a general rule of thumb, said Chris Troyanos, ATC, the long-time medical coordinator for the Boston Marathon, the medical surge capacity of a race will be about 1-2% of field size, meaning the largest number of athletes needing medical help at one time. That number will be higher, though, if the race is hotter or longer. Marathons, on average, see medical encounters of about 2% of the field.

Weather is the biggest factor in determining how many athletes will need medical assistance, with the rate of medical encounters more than doubling in “hot” years and the number of heat-related issues skyrocketing, according to Dr. William Roberts, the medical director for the Twin Cities Marathon, as defined by the WetBulb Globe Temperature, which takes into account humidity and direct heat stress. (What constitutes hot can depend on seasonable weather and how acclimated the athlete population is, and how long the distance is.) Over 69 degrees on the WetBulb Globe Temperature can be medically problematic for something as long as marathon.

No matter the size or climate of the race, though, there are best practices to prepare for what is, essentially, a controlled medical disaster. You know there will be issues, you’re just implementing plans and procedures to control and prepare for the most serious of them.

Common medical issues you need to be prepared for

The absolute most common issues runners come into medical tents for—both on-course and post-finish—are typically musculoskeletal and soft tissue, GI, or heat-related. That means blisters, cuts, cramps, strains, joint pain, nausea, bloating, and GI distress. Various analysis of multiple races has found that these account for a large number of medical encounters.

However, both Roberts and Troyanos noted that the more important things to be prepared for, rather than just the most frequent complaint, are the most common serious medical issues. These are the things, beyond blisters and muscle cramps, that every race has to absolutely plan for.

Exercise associated collapse

According to Roberts, our understanding of what is called exercise associated collapse has evolved over the years. This phenomenon when runners are unable to stand up after finishing a race is not actually likely to be caused by dehydration; it’s now considered to be a result of postural hypotension. What that means is that your legs operate as a kind of heart when running, Williams explained, with large muscles pumping blood throughout your body. When you stop, they’re no longer doing that and the accompanying drop in blood pressure can cause that post-finish collapse.

In Roberts’ tracking of medical encounters at the Twin Cities Marathon, over 26 years, nearly 90% of non-musculoskeletal or skin issues were exercise associated collapse (accounting for nearly 60% of total encounters). It is the most common medical condition at race finish lines.

For every cardiac arrest he’s had to deal with, said Roberts, he’s probably seen 10 exertion heat strokes and maybe 2,000-3,000 exercise associated collapse.

The key thing to know about exercise associated collapse is that it’s important to rule out any more serious issue causing the collapse, such as exertional heat stroke. This is where a medical professional is key to evaluating the athlete, talking to them to ensure that they’re conscious and coherent, and then establishing a protocol. Most athletes who find themselves unable to stand just need to put their feet up and give themselves a little time.

Exertional heat stroke

The next most common medical issue at the end of a race is heat-related, with various events finding heat-related issues to account for 20-30% of medical encounters. But exertional heat stroke is the most serious of those conditions, when an athlete’s core body temperature has risen above 104-105 degrees F and does not come down. Exertional heat stroke can typically be noted by disorientation and incoherence, dizziness and collapse, nausea, and of course a heightened temperature. Both Roberts and Troyanos note it’s necessary to have a rectal temperature taken in the medical tent in order to diagnose and treat these cases.

In an analysis of 100,000 runners across 10K road races, 600 medical encounters occurred with 25% of them being heat-related and 94 requiring ice tube water immersion for exertional heat stroke. In Williams’ tracking of Twin Cities Marathon data over 26 years, they had 3,269 medical encounters with about 30 severe exertional heat stroke—meaning a core rectal temperature of over 109 degrees F—and four heat stroke transfers to the hospital.

Treating heat stroke requires cooling the athlete, either through ice tub immersion or a rotating system of ice cold wet towels that are changed when they get warm and ice packs. Setting up a plan to deal with heat stroke is an absolutely necessary best practice when preparing a medical plan.

Exercised induced hyponaetremia

Hyponaetremia is the next most common serious medical issue, with the Twin Cities Marathon numbers accounting for two severe and three more mild cases over the 26 years. Asymptomatic mild EAH has been found to actually have an incidence of up to 12-13% of marathon runners, when blood levels were tested, but it’s the symptomatic EAH you need to worry about.

Hyponaetremia is when blood sodium levels fall below 135mmol/L. This can be extremely serious if sodium serum levels fall too low and can be especially serious if symptoms are mistaken for dehydration and more water is consumed, further dropping sodium levels.

Most frequently this occurs in athletes, as EAH, because of over-hydration, and a common symptom to observe would be weight gain because of the inability to urinate out or sweat excess fluid. However, the symptoms of EAH can be as mild as nausea, dizziness, and a headache, and can progress to altered mental states and seizures. Medical best practice would be to have a way to test serum sodium levels in the med tent at large events, otherwise medical personnel will have to rely on symptomatic case assessments. If the athlete is able to keep food down, then treatment in most cases would be consumption of salty food and high-sodium concentrated broths, but if an athlete is overly nauseous or symptoms are serious, then a hypertonic saline solution may be necessary.

Anaphylaxis

While relatively rare, anaphylaxis—an extreme allergic reaction—can be life-threatening. If a runner goes into anaphylactic shock from a bee string, for example, as the most common allergic reaction on a race course, then it can cause cardiac or respiratory arrest. Having epinephrine on hand can be life-saving in these instances.

Cardiac arrest

Although cardiac arrest is not very common, said Roberts, and typically happens at a rate of just one per every 50-100,000 runners, when it does happen it’s the most serious medical emergency you can have.

“Even the small races need to be prepared for that,” said Troyanos. That means having an automated external defibrillator on hand, with a paramedic or EMT who can properly administer it, and a plan for how to quickly get that AED to the person in cardiac arrest. (Find planning best practices here.)

Preparing for the most common and most serious medical issues you’re likely to see at a running race mean investing time and money into the key medical equipment and resources, having medical personnel on hand, and establishing a plan in the event one or all of these things happen.

About the Author

Kelly O’Mara is the former editor-in-chief of Triathlete Magazine and the founder of the Triathlonish

It was a Boston Marathon to remember.

The first edition of the race to ever be held in the fall, the 125th Boston Marathon marked the race’s triumphant return after two missed April iterations due to the pandemic.

We chatted with Lauren Proshan, director of operations for the Boston Athletic Association (B.A.A.), to get her perspective on how the race went and what’s in store for the 126th Boston Marathon, set for Monday, April 18, moving back to its traditional Patriots Day timeline.

“I wish I had a better word than awesome, but just to see everyone’s sheer excitement and relief to be back on the roads was truly awesome,” said Proshan, still smiling at the memory. “The city as a whole felt completely alive. And not to mention, there was a Red Sox playoff game that evening. So, there was just this very cool feeling of excitement throughout the whole day.”

Runners expressed it in droves.

“We passed Wellesley (College) with the famous screaming tunnel which was super cool and they were all screaming with some very interesting signs they were holding,” said Harris Craycraft, a marathon finisher and YouTube blogger who made a video about his experience. “This was the point where they would normally kiss runners, but they couldn’t do that because of COVID, and that was OK.”

Runners’ acceptance of the changes necessary to adapt to pandemic-era racing conditions was an invaluable factor for every event, large or small, that went on this fall. And in Boston’s case, the change to a rolling start in Hopkinton was so popular that the race is now under pressure to keep it. Runners didn’t have to wait for long periods in their pre-assigned corrals, they simply got off the transport buses, made their way to the start line and were able to begin their race.

Veteran running journalist Amby Burfoot put it this way: “No wait time in a chilly, uncomfortable Athletes’ Village? What’s not to like? In an online poll at Boston Buddies, a Facebook group, fully 90 percent of over 500 respondents said they’d like to see the rolling start become a fixture in future Boston Marathons.” (Read the article here.)

We asked Proshan about the rolling start and runners’ affection for it. She noted: “What a lot of folks may not know is that we had to request an additional hour of time on the road to make this happen. We do run through eight city and town jurisdictions, and that means getting permission from eight cities and towns to have their roads closed for an hour longer.”

But that being said “we’re already talking about whether there is a hybrid model? Is there a different way to reduce that time in the Athletes’ Village or just waiting at the start area in general? Nothing’s off the table, and we certainly heard loud and clear what people like.”

In addition to the innovative start, 2021 provided an opportunity for the B.A.A. to revamp its finish line setup and credentialing system.

“With partner John Hancock’s blessing, we took that program in house and revamped what it meant to be wearing a credential at the event,” explained Proshan. “We simplified the system by simplifying our boundaries, and by default made the event much more simple and secure.” The change helped enhance social distancing in the finish line area.

The finish line renovation, constructed from “the world’s coolest building blocks and Lego-style construction system,” as described by Proshan, also involved removing the spectator bleachers that have long been a Boston fixture. In past years, more than 3,000 people would typically cram in to watch the emotion and elation as runners crossed one of the world’s most coveted finish lines.

“It provided a much cleaner, spectator-friendly area. It’s one of those things we will be having long discussions about going forward. But because of the pandemic, we were able to see something in a different way that we had never done before. We will bring back a version of it, but it has forced us into reimagining what that will look like.”

On Nov. 2, the BAA announced that the field size for the April 2022 Boston Marathon will be 30,000 and all accepted runners must be fully vaccinated to participate. With a timeline of less than six months to produce one of the most historic races on earth, Proshan and her team are already off and running.

 

Known throughout the events industry for dedication to operational excellence and preparedness, the 2021 Bank of America Chicago Marathon excelled on both fronts on Oct. 10, when it returned with the largest U.S. marathon field since the start of the pandemic.*

Just over 26,000 runners participated in the event, under the 35,000 capacity cap announced by the race in June. The pre-pandemic Chicago field cap was set at 45,000 participants.

To ensure the safety of all participants and anyone involved with the race, participants were asked to submit proof of vaccination or a negative COVID-19 test result to access marathon events and run on race day. Early communication to registrants set clear expectations. Ultimately, runners were so eager to get back to the start line that many showed up with both a vaccine card and a negative test result.

“We saw a lot of people coming in with their proof of vaccination AND a negative test. There was not a lot of push back (on those requirements) from our participants. Instead, we got thank yous,” said Carey Pinkowski, CEO and President of Chicago Event Management (CEM), which produces the marathon.

But even with planning and approvals in place, the late-September postponement of the Tokyo Marathon, a fellow World Marathon Major, and 2021 Marine Corps Marathon meant that all eyes were on Chicago to see if the race would go forward.

“When we went out and painted the blue line about five days earlier than we usually paint it, that was all people needed to see. People said well, they wouldn’t have painted the line if they weren’t going to have this race,” Pinkowski said. The blue dashed line runs the duration of the marathon course and marks the most direct route to the finish.

Dr. George Chiampas, Medical Director for the marathon, said he believes that the enthusiastic reaction of runners to vaccination and testing requirements is a positive sign for events of all sizes.

“Runners gravitate to those events that put their best interests and safety at the core of the event, and they want to be a part of those events,” Dr. Chiampas said. Chicago’s comprehensive verification system included dogs trained to detect the presence of the coronavirus in human sweat and identify candidates for additional screening were used on site as an added safety measure.

The effort and preparation required to ensure COVID safety did not distract the CEM team from its continual mission of thorough preparation for potential contingencies.

“One of the great things that Mike (Nishi, COO of CEM and operations lead for the marathon) did was say, we’re focusing on COVID, but let’s not lose sight of other things. Our security, emergency action and evacuation plans were all still at the forefront as we planned,” Pinkowski said. Proof of that was reinforced by an incident free day. Aside from less than ideal warm and humid weather, runners were happy.

“I think we underestimated how excited we were going to be to be out there racing a race of this magnitude again,” said Mike Ko, a non-elite Chicago runner and vlogger who ran 3:14. In a post-race video, he notes that the 3:10 pace group is running with exuberance during the first 10K of the race as he attempts to keep up.

With the reduced field size, Dr. Chiampas and his medical team were ably staffed to handle participants suffering from on-course medical issues. But one factor that he urges races to consider as the pandemic wanes is bandwidth and burnout in the medical community.

“With COVID, you have to really understand what your health care volunteers are going through in the medical space. There’s a massive component of fatigue across all disciplines, and now you’re asking them to come out on their day off and provide their services,” Dr. Chiampas said. “Your private ambulances, city employees, police and fire personnel – they’re all being stretched. You really need to engage with those entities to make sure appropriate safety and security is in place.”

The better news, as Dr. Chiampas sees it, is that the successful return of Chicago and fellow World Marathon Major events Berlin, London and Boston is excellent proof of the industry’s return to normalcy. “Running is back, and these major events have taken place safely. I feel really excited about the future of running,” Dr. Chiampas said.

Pinkowski reflected on the dark days of winter 2020, before the availability of vaccines gave a glimmer of hope that races could resume.

“It was a terrible time of indecision and not knowing the unknown, which is the most intimidating thing you can experience. But we stuck together. People in the industry collaborated, and talked, and picked each other up. We all had a goal of getting there in a safe and secure way. And we got it done.”

*The New York City marathon surpassed Chicago to become the largest race held in the U.S. this year on Saturday, Nov. 7.

This spring, Running USA was able to spearhead the production of a research-based white paper that will help races get started again. Recognizing that every area of the country is different, and protocols and regulations are constantly changing, epidemiologist and medical modeler Dr. Brooke Nichols has outlined the safest way for running events to get back to the starting line.

Dr. Nichols brings a perfect mix of skills to this project. In addition to her epidemiology background, she has spent much of her career focused on mathematical modeling of HIV transmission. She’s also a dedicated runner who has completed the famous Comrades ultra. In 2020, those experiences came together when she was asked to help the Boston Athletic Association and other organizations with the science behind racing safely.

Dr. Nichols recently sat down with Running USA for an interview on COVID-19, running, and her expectations for our industry and getting back to normal.

If you haven’t had a chance to read the white paper, find it here by clicking through to a downloadable version. Many events have told us that they are taking this white paper with them as part of their permitting negotiations with city and county officials in advance of summer and fall events. Thanks to the Bank of America Chicago Marathon, Chicago Event Management, Brooks Sports and P3R for their sponsorship, which made this project possible.

Tell us a bit about your background and how you decided to pursue quantitative implementation science?  I don’t think it’s something that most little kids dream of, becoming a mathematical modeler when they get older.

Dr. Nichols: No single scientific method is enough to answer some public health questions. I was trained as an epidemiologist and infectious disease epidemiologist, and in the mathematical modeling of infectious diseases. But the number of tools that you need to answer so many questions in public health is large. Modeling isn’t enough, epidemiology isn’t enough. Sometimes you need health economics, and you need to bring all these other disciplines together. And so that is what we’ve been calling quantitative implementation science. And as a little girl, obviously, quantitative implementation science wasn’t a thing because I was not grown up yet.

I’d always been interested in the fact that you can use math to explain the world around you. So that’s how I initially got started. My background is mostly in HIV modeling, and looking at different policy decisions around how can you prevent infections, as well as have you invested resources properly to ensure maximum impact?

And then, along came coronavirus. How did that change your daily work?

Dr. Nichols: At least half of my time has been spent on coronavirus since March of last year. Because it turns out there’s not a lot of infectious disease modelers out there. Infectious disease epidemiologists were in high demand, and we pivoted all of our skill sets to work on coronavirus. Over the past year, my primary work has been working with country governments to look at testing policies and global resource allocation specifically for coronavirus testing, and rapid antigen diagnostics. And I’ve been working with running events as well.

How did you get started working with running events?

Dr. Nichols: I’ve been running distances from 5k to ultra-marathons and been an avid runner for as long as I can remember.

A former classmate of mine from my epidemiology studies was working with the Boston Marathon. He said, Brooke, you’re an actual infectious disease epidemiologist, and I know you run a lot. So why don’t you come talk to us, and we can see what we can figure out. And so that was my first connection between infectious disease epidemiology and my greatest passion, which is running. Since then, I’ve been serving on the Boston Marathon COVID-19 Medical & Event Operations Advisory Group.

And we understand you’ve worked with some other major industry events as well?

Dr. Nichols: Yes, I have also done some work with Bank of America Chicago Marathon and Spartan event series over the last several months.

With our race director audience in mind, what are the scientific and health factors that need to play into their planning for events this year and beyond?

Dr. Nichols: Coronavirus has evolved so rapidly, and our response has evolved rapidly. In a lot of ways, planning is about having a plan for  the worst case situation. For example, if vaccination isn’t scaled up to the extent we thought it was going to be, then what’s the plan? And trying to plan around that, instead of assuming that we’re going to hit certain targets. Because public health is notorious for not achieving the targets that they hoped that they would. But I do think we know enough now about the virus, how its transmitted, and almost all the key factors that come into running (and producing) a race.

In the white paper you wrote that temperature checks are not useful or necessary for large events. Can you explain that?

Dr. Nichols: Temperature checks are very likely to get the answer wrong. If you do not have coronavirus, it is likely to say incorrectly that this person needs to be screened out because of elevated temperature.  The other way around, I could have coronavirus and no temperature, and it would not screen me out.

The Cochrane Review, a systematic review of research in health care and health policy, has come to this specific question of the usefulness of temperature screens and they’ve also concluded that they are not very useful. And in many people with COVID, especially asymptomatic infection, the probability of having an elevated temperature is low. You’d actually miss your most important group of people, those who are infected but not exhibiting symptoms.

Another conclusion that was interesting is that surface transmission of coronavirus is something that we don’t really have to worry about. Can you explain why that is?

Dr. Nichols: Early in the pandemic, we actually had no idea whether it was fomite transmission (surface contact transmission) or airborne aerosol droplets. I mean, the CDC didn’t officially agree on how it was transmitted until about a week ago. (Ed. note, conversation took place May 4, 2021.)

But now there’s been enough data and enough people infected with coronavirus that we now know that the vast majority of transmission events occur through the air, via people breathing, and not through surfaces. There are very few cases that can be linked directly or proven through just contact on surfaces.

 In the white paper you also talk about testing protocols and timeframes for doing testing. Can you talk a little bit more about that?

Dr. Nichols: There’s been a lot of discussion about rapid antigen diagnostics vs. PCR testing.  Most everyone considers PCR testing as the gold standard, which it is to some degree as it detects virus. So if you have virus alive and replicating that’s transmissible, or dead virus, where you can no longer infect someone, it will pick up the virus and say that you’re positive. For example, if I was infected three weeks ago, and I coughed on you today, I wouldn’t actually give you coronavirus. But the test would say that I’m positive still.

But the PCR test is good because it can pick up virus before you start transmitting, maybe a day or two in advance. Whereas an antigen test can only tell you sort of at that moment forward that you are no longer or that you are currently infectious. So antigen tests are actually really good testing tool to say whether or not you’re going to transmit the virus. Whereas PCR can give you a tiny bit of a signal ahead of time.

The other difference is that PCR testing typically needs to go to a lab, and there’s a turnaround time, so you don’t actually know the result of your test until a day or two later. With rapid antigen tests, you know straightaway.

What are the implications here for events, differentiating between the small local events and large events with tens of thousands of participants?

Dr. Nichols: I tried to make the distinction in the white paper about large scale events. And when I talk about large scale events, I mean when people are traveling into a city or community from elsewhere. The reason that that matters is because not only are we trying to keep our races safe, but if you’re bringing in 50,000 people; not only the participants, their families, and others, all into an area that didn’t have those people before, there could be an impact. You could make the race safe, with no transmission events, or very few transmission events. The consideration would be the impact on the community. It’d be participants and their families and others who are part of the event, interacting with the local community at restaurants and social events around the race, that would be more of concern.

When we’re thinking local events, typically participants are just going to drive to the event the same day, they’re not staying in a hotel, they’re not going to different restaurants than they normally would, then you’re not going to impact the community differently.  When events are smaller and local, you wouldn’t necessarily need to use a testing strategy. But at a large event where you’re having people come from multiple locations, that testing strategy becomes more important. If you had access to rapid antigen tests, you could certainly consider that as part of your mitigation strategy at a small community event. But it matters to a lesser extent to global public health then it does at a large event.

Is coronavirus eventually going to fall off our radar like SARS or Zika? Or do you think it’s something that we all have to worry about for years to come?

Dr. Nichols: We’re going to worry about it for forever. Eventually we will worry about it less, because it will kill people less frequently once people are vaccinated. But this is something that will become, by my estimation, endemic.­ We can’t get rid of it. If we could really vaccinate everyone in the world at the same time, maybe, but that is incredibly unlikely. This will more likely become more of a seasonal virus or a childhood virus potentially.

Editor’s Note: This Best Practice Guide was contributed by William O Roberts MD, MS, FACSM, FAAFP. Dr. Roberts is a Professor and the Director of Faculty Affairs in the Department of Family Medicine and Community Health at the University of Minnesota in Minneapolis, Minn. He also serves as the Medical Director for the annual Medtronic Twin Cities Marathon in Minneapolis, and in that role has developed his expertise in medical operations for road races.

The medical care plan for road races can vary from simple to complex. Larger races are set up to deliver onsite care to reduce the patient load on the community medical system and have systems in place to respond to life-threatening medial problems.

All races, including smaller races, should develop a medical plan for runner safety that has a written set of safety parameters agreed upon in advance with contingencies for heat, lightning, high winds, cold, and other safety concerns. The plan should include a specific emergency action plan (EAP) for rapid response to life threatening problems. From 5K to 100K, the causes of runner collapse are similar, but the list of life-threatening medical problems changes with increasing distance and increasing heat stress.

Injury and Illness in Road Racing

The race team medical protocols should address both the serious and common medical problems that confront runners in each event. The basic differential diagnosis for the runner collapse is:

• Sudden cardiac arrest

• Exertional heat stroke

• Exercise associated hyponatremia

• Anaphylaxis

• Insulin shock

• Asthma

• Exercise associated collapse (exercise associated postural hypotension)

Exercise associated collapse is by far the most common of these problems and is essentially a “diagnosis” of exclusion. Exercise associated collapse or exercise associated postural hypotension also tends to occur more frequently in hot and humid conditions and in longer races. Although runners may appear in distress, this problem responds to leg elevation in the supine position or if the runner can stay upright, assisted walking. This is a diagnosis of exclusion and the runner should have a good heart beat, be breathing well, and be able to answer simple questions.

Other far less common, but potentially fatal causes of runner collapse are sudden cardiac arrest, exertional heat stroke, and exercise associated hyponatremia. Hypothermia (decrease in serum sodium concentration caused by excessive water intake) also occurs in cool weather races, especially if associated with rain. Dehydration is not very common in road races where water is readily accessible but can occur and is often incorrectly assumed to be the cause of runner collapse.

Injuries and illness can occur at any point along a race course. Over time races learn their trouble spots, like the top of a long hill climb or the bottom of a long downhill segment. The finish area tends to have the most medical encounters as runners stop or slow, and the physical toll of the race begins to show. Most problems are short lived and time limited. Factors that influence medical encounter rates include race day weather, event distance, event type, and the health, fitness, and acclimatization of participants.

It is clear from anecdotes and case reports that when weather conditions are warmer and more humid than the area averages and recent actual weather conditions, the risk of EAC, EAH, EHS, and race dropouts along the course increase. In general, the higher the wet bulb globe temperature (WBGT) conditions (high humidity and above normal for season temperatures) the greater the number medical encounters, race drop outs (before and during the race), and both exertional heat stroke and exercise associated hyponatremia cases.

Medical encounters increase with the race distance, hot and humid weather, and cold and rainy weather. Marathon (42K/26.2 miles) finish line encounter rates vary from 1-6% of finishers at the Medtronic Twin Cities Marathon and have been as high as 10% in hot, humid conditions at other marathon races. On average, the number of starters who do not finish plus the number of medical encounters per 1000 finishers at the Twin Cities Marathon rises from 40-60 in cool (start WBGT 30-55° F) conditions to 160 in warmer conditions (start WBGT 72°F).

The Army 10 Miler, held each October in Washington D.C., has about 4 medical encounters per 1000 starters, but on two recent hot and humid race days had runners experience 30 exertional heat strokes. Runners with heat stroke require immediate care involving 2-5 medical providers for 20-60 minutes, so treating 30 heat stroke casualties on site in a short time span will involve 60 to 90 volunteers.

In cool weather conditions most participants who start a marathon or other distance race will finish, but the combination of cold and rain also increases race drop outs and finish area medical encounters.

Sudden Death and Cardiac Arrest

Runner related deaths are usually due to cardiac arrest (SCA), exertional heat stroke (EHS), or exercise associated hyponatremia (EAH). Sudden cardiac arrest in the marathon is the most studied, ranging from 1-3 per 100,000 finishers with about half saved by rapid response teams using CPR and defibrillation. The emergence of portable and easily applied automatic external defibrillators (AED) has improved the risk profile for participants of mass participation events. Mobile teams on bicycles or carts equipped with AEDs that can rapidly move along the course are key to reducing time to defibrillation. Teaching hands-only CPR to non-medical volunteers, runners, and spectators may also improve outcomes with more people available to initiate CPR. The most likely first responder to a collapsed runner will be another runner in the race.

All races should be prepared to address cardiac arrest. Most community recreational events will involve older participants who are at more risk for sudden cardiac arrest. The risk for cardiac risk may be greater in high heat conditions as removing heat from the body increases cardiac demands. Integrating the emergency response system into the medical is essential for rapid response to runners who collapse from cardiac issues. SCA requires immediate transfer to an appropriate cardiac care center.

In cardiac arrest cases, the initial response plan is to activate the emergency medical system, start hands only CPR, and apply an automatic external defibrillator as soon as possible. It is the lifesaving electric shock from a defibrillator that has the greatest impact on survival. Although cardiac arrest seems to be a finish line problem, an arrest can occur at any location along a race course and at any race distance. Survival is highly correlated with defibrillation and the advancing technology has made automatic external defibrillators readily available and relatively inexpensive. It is important to set up a system to access runners stricken by cardiac arrest with a defibrillator as rapidly as possible. At Twin Cities Marathon, we use bike teams and golf carts to shadow the runners along the course. An AED at the finish area is also an important asset.

EHS and EAH are life threatening emergencies that can be treated onsite (treat first, transfer later). EHS is about 10 times and EAH is about 4 times more common than SCA in hot weather races. On site care can avoid delayed diagnosis and treatment in an emergency department and shave critical minutes off the time to treatment. Emergency departments may not have the necessary equipment and supplies for rapid treatment readily available or delays in treatment may occur while protocol-based imaging studies are obtained. Working with the community emergency medicine resources can help avoid treatment delays in participants who do not present to the event medical facilities but enter the medical care system through ambulance transfer or after the race has completed is critical to runner safety. EHS and EAH have the potential for full recovery if recognized and treated immediately.

The local EMS providers and hospitals should be aware of your event and if there are over 1000 participants, an on-site ambulance is probably prudent. Notifying area emergency facilities in advance of your event and potential casualty types will allow time to adjust race day evaluation and protocols and increase staffing on race day to accommodate the anticipated increase in patient care volume.

General Medical Problems

Runners most often seek care in three basic categories: medical, musculoskeletal, and dermatologic. There is a very small percentage of serious medical problems including cardiac arrest, acute coronary syndrome, EHS, EAC, anaphylaxis, insulin reaction, and completed stress fractures where immediate intervention can reduce morbidity and mortality. The remainder of the medical issues are generally non-life threatening and self-limited but require intervention to resolve the issue and keep the patient load off the community emergency medical system.

The most common medical condition following endurance activity is exercise associated collapse (EAC) or exercise associated postural hypotension (EAPH), which is usually self-limited and resolves spontaneously with rest and leg elevation. This accounts for 60% of the medical encounters and 90% of the encounters that were not related to musculoskeletal or skin issues at Twin Cities Marathon and is the leading cause for evaluation in the finish line medical tent. The subset of musculoskeletal conditions is mainly sprains and strains with occasional stress fractures and aggravated tendinopathies. Blisters and abrasions make up the bulk of skin issues. The distribution of injury and medical issues vary by event length with short distances having the least number of medical issues.

Using medical protocol algorithms to standardize care among clinical staff will make the delivery of care more efficient and should improve outcomes. The basic medical evaluation of a collapsed runner is to look for spontaneous breathing, high rectal temperature, low serum sodium (in longer duration events), signs of anaphylaxis (facial, tongue, or throat swelling or restricted breathing, medical alert tags for chronic disease, and improvement with legs elevated. Putting the athlete in the “feet up” position at the start of the evaluation will begin the redistribution of fluid to the core and speed recovery for EAPH.

Who Gets an IV in the Field?

Intravenous fluids are rarely needed in the management of collapsed runners except for the very small number of serious medical problems. Over 12 years of finish line care at the Twin Cities Marathon, there were only 106 IV starts for 81,300 finishers. The main reasons to start an IV are fluid replacement or medication access. The following table outlines the criteria we use for starting an IV at Twin Cities in Motion events. The number of IVs started will likely vary with the training of the physicians and the comfort with the presentation of “collapsed” endurance athletes; physicians with less experience tend to start more IVs, so close supervision by experienced staff will reduce unnecessary IV starts.

Fluid replacement	Hypoglycemia (<60)
After leg elevation 10-30 min with limited resolution	Anorexia (lack of thirst or hunger)
Orthostatic BP drop after leg elevation	Vomiting or nausea
BP < 100 sys & symptomatic	Diarrhea
Temp >104 or <95 and not responding to treatment	Confused
Severe muscle cramps or spasms	“Not doing well”

 

Disposition and Discharge Criteria

The disposition and discharge criteria should be determined in advance of the event by the medical team. At TCM events, we discharge runners when they are clinically stable, have a normal rectal temperature, and can walk without assistance. The first stage following recovery from self-limited EAPH collapse is the “sit test,” which involves moving the patient to the sitting position to check for an orthostatic reaction. If this change is tolerated, the next move is to stand up, and if tolerated, walking.

Before departing the onsite treatment area, the runner is given our written discharge instructions that discuss continued fluid and energy replacement, the criteria for reevaluation, and follow-up recommendations. Ideally the runner is handed off personally to family or friends as part of the transition out of the medical area. Runners with more severe problems or not responding to the usual treatment protocols are transferred to an emergency facility. Runners with cardiac chest pain or acute coronary syndromes, shock, blunt trauma, initial rectal temperature <92ºF meet our criteria for automatic transfer. However, those with EHS are cooled first and then transferred unless they are clinically unstable or in cardiac arrest.

Mass Participation Event Planning

Every race should have and emergency action plan (EAP) that is integrated into the community emergency response protocol. A comprehensive EAP will leave the emergency departments and emergency transport systems available for the community and the event participants truly in need of advanced care. These “planned disasters” are convenient community disaster training experiences for future disasters that may confront a community. The International Institute of Race Medicine has race management materials and a race medicine handbook to assist races with protocols to improve or develop race medical care teams.

The medical plan should include education for the medical and general race volunteers so all are using the same protocols and have the same expectations. This is especially important when it comes to unexpectedly hot weather and expectations for runner fluid consumption during the race. Education during in-person race and medical team meetings, with written materials, and/or via web-based modules outlining both the medical risks and the evaluation and management protocols will improve the care on race day.

The EAP should address all potential adverse events that can alter the race including high heat and humidity, severe storms, lightning, high wind, freezing rain, terrorism or threat of terrorism, vehicles infringing upon the course, potentially dangerous animals, and political demonstrations. All have disrupted or cancelled events around the world.

 

Planning in close cooperation with the community emergency personnel allows a rapid transition in the chain command in the face of natural or man-made disasters. Many communities require integrating public safety and emergency medical responders, law enforcement, public health and homeland security into the emergency response plan as a part

 

of the event permitting system.

The idea that nothing will cancel or modify an event for runner safety has largely disappeared from road racing administration lore, with cancellations of major events at the hands of nature (in the wake of a hurricane, heat, and lightning storms) and unfortunately at the hands of man (terrorist bombing – Boston Marathon 2013). Events must also determine the community medical capacity to care for event casualties in addition to the emergency needs of the community. Planning is important to ensure that a high volume of race medical incidents will not disrupt routine or emergency community care.

Preparation for an event medical team will depend on location, race distance, number of participants, and the most likely injuries and medical problems. Establishing a medical team that can respond to the worst-case race casualty scenario will improve the safety profile for the participants and not force medical volunteers to overextend their care capacity or to work above their medical license and training.

 

Race planning should start 6-12 months prior to the race to develop medical protocols, supply and equipment lists, personnel needs, communication protocols, rapid medical response plans, disaster (crisis) plans, cancellation parameters, a heat ramp up plan, participant and volunteer education materials, and volunteer recruiting plans. On race day, the decision to start the race should be based on safety parameters determined in advance by the race and medical committees. After the race, a post-event report outlining what went right, what went wrong, and what can fix the problem(s) will help with planning for the next race.

 

A medical director (MD/DO) with an interest in race medicine can help organize the medical team and develop the medical protocols. A medical coordinator with an allied health background can be an asset to the medical and race management teams, fulfilling many of the administrative functions and leaving the medical director to deal with medical protocols and race safety issues. The medical director must be a part of the race management decision making process and should sit on the executive administration committee to represent the participant safety and medical interests.

The medical director and team, in cooperation with the race administration should address the following areas in preparation for race day. Race volunteer safety should also be considered in the race plan.

 

Course medical care	Adverse event protocol
Family waiting	Disaster or adverse event counseling

 

Assembling a Medical Team, Use of Volunteers

An interdisciplinary medical team of physicians, physicians in training (residents and medical students), physician-extenders (physician’s assistants and nurse practitioners), athletic trainers, physical therapists, registered nurses (especially from emergency departments, intensive care units, and cardiac care units), paramedics, emergency medical technicians, first aid providers, and students than can assess and manage medical, musculoskeletal, skin, and sometimes trauma issues that arise during and after races.

Non-medically trained volunteers can help with tent set up and organization, equipment and supply management, scribe for medical record completion, retrieve clothing bags, and other functions that do not require medical training. Volunteers shift length in the 4-6 hour range is reasonable, and longer shifts lead to fatigue and attrition. Medical volunteers should be readily identifiable to participants and other race volunteers. A distinctive T-shirt, jackets, vests, and/or hats work well and provide a thank you gift for each volunteer that doubles as a marketing tool for future races.

The number of volunteers needed to provide adequate care during the race will depend on the number of entrants, the length of the race, the anticipated encounter rate, and the peak finisher flow. Peak finisher flow often correlates with the peak in medical encounters. For a marathon the peak runner flow is often in the 3.5-4.5 hour mark and for a 10 mile race may be in the 80-100 minute range.

Estimating the number of volunteers needed is easier when there is race data to assist with decision making. At Twin Cities Marathon, we utilize just over 300 medical and communications volunteers for approximately 19,000 finishers of the marathon and 10 mile races (16 volunteers per 1000 finishers). The volunteers are distributed along the course at fixed medical stations, fixed first aid posts, mobile bike teams, and mobile cart teams. The largest group of volunteers is assigned in the finish area to runner triage and medical tent care teams.

A tent or some form of shelter for privacy and protection from the weather will be needed for evaluating and treating runners with problems. The medical evaluation area should be located downstream from the finish line and ideally near an access site for ambulance evacuation of serious casualties. Fencing to limit access to the medical area is essential for privacy of runners who require evaluation and treatment. Except for rare circumstances, family members are not allowed in the medical treatment area to preserve privacy for other runners in the med tent “ward-like” space and to reduce the chances for inadvertent exposures to blood borne pathogens.

The medical equipment and supplies are focused on the “usual” casualties for a given event.

Items include cots, tables, chairs, gas heaters, fans for circulating air, tubs for ice baths, microwaves for heating blankets, ice chest for ice and water, water supply, blankets, towels, tables, chairs, drape partitions, lighting, toilet, and handwashing station. Convenience supplies like sanitary pads, tampons, contact cases, and contact solution, are helpful and can help smooth transitions out of the medical areas. The amount of supplies will vary with the conditions with more cooling supplies and equipment needed on hot days and more warming supplies for cool days.

A communications system for race day that covers the course is essential to assist the medical team and respond to on course emergencies. It is helpful to have some redundancy in the plan to account for system failures. A combination of cell phones, hand held radios, and HAM radio operators allow rapid, but not always confidential communications. Text messaging, email, and web sites can be used to pass information to volunteers and competitors regarding cancelations, delays or changes. A dedicated emergency phone number distributed to all volunteers allows any race volunteer to report a medical incident and ensure rapid response.

An emerging medical communication and medical record tool involves mobile phone and tablet apps that can be connected to GPS for detecting emergency incident location detection and can be used to simultaneously record the medical event in real time. When used on a mobile

phone, the app can be used to connect to race command, EMS dispatch, and the participant’s emergency contact with a radio button link. These apps can also be used by participants to record their personal medical data regarding chronic health issues, medications, allergies, and usual training or pre-race weight. This information is valuable to medical responders and can speed the care of race day problems. This information traditionally has been collected on the back of the competition bib. The apps have made the data more private and easily accessible at any point on the race course.

Course and Finish Line Fluids

The planning for course and finish line fluids is not an exact science. There are formulas that help with the calculation and the calculations are complicated by having more than water available for fluid replacement. Water should be adequate an adequate fluid for most runners in most race situations. Here is a simple minimalist approach: one 210-300 ml cup per entrant per aid station with 120-240 ml fluid in each cup (double the number of cups for the start and finish areas). If you have a sport drink in addition to water, you will need to have both available at each water stop; a starting estimate would be 2/3 of the total water calculation for each station, although this estimate runs a risk of running out of one fluid or the other at an individual station. If the temperatures are going to be hotter than normal for the season, you may have to increase the number of cups by 50-100% as participants will often drink one or two cups of fluid and dump one on their body. An on-site potable water source (fire hydrant) will make the water volume a non-issue, leaving the cup estimate as the limiting factor (cups can be stored and used for the next event). A military style “water buffalo” is another option for transporting bulk potable water. Sports drinks can be mixed on site using bulk powdered formulations.

After the finish, soup bullion can be a good initial rehydrating fluid to give the athlete an initial salt load (have a vegetarian option), in addition to water and sports drinks. Chocolate skim or 2% milk is also a good post event rehydration fluid.

Documentation and Review

For each race it is desirable to record the weather conditions including ambient temperature, relative humidity, sky cover (% sun), wet bulb globe temperature, black globe temperature, wind speed and direction, and WBGT (measured on site or calculated from race data) at the start and hourly through the race. This allows comparison of injury rates from year to year and event to event.

Documenting each encounter is essential as each medical record becomes the legal record of the care. The records can also be used to look at the type and rate of injury associated with the race. Good records augment future planning and distribution of medical assets.

After the event, at the Twin Cities Marathon we ask for a post-event report from each area leader. The general report format is “what went right, what went wrong, and what are potential solutions for the next event.” This format usually allows the medical team to gain perspective and make relevant improvements to runner safety and medical team efficiency.

 

Sample Medical Record from Twin Cities Marathon (This may be reproduced for your race)

 

 

 

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