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Medical Planning & Management Road Race Management 2006 William O Roberts MD, MS, FACSM Medical Director Medtronic Twin Cities Marathon & Associate Professor.

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Presentation on theme: "Medical Planning & Management Road Race Management 2006 William O Roberts MD, MS, FACSM Medical Director Medtronic Twin Cities Marathon & Associate Professor."— Presentation transcript:

1 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

2 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

3 Why Address Safety & Medical Operations For Your Race?  # 1 priority Medtronic TCM  Medical events & safety breaches –Potential for  Bad press  Liability  Runner catastrophe

4 Where to Put Your Money ALS ambulances & staff Defibrillators for course Medical volunteer identification Communications system

5 Race Medical Operations Role in Race Operations  Optimize event safety  Provide medical care  Make medical decisions  Act as medical spokesperson

6 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

7 Race Medical Operations Purpose  Post-race –Make it better

8 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.

9 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%

10 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

11 Risk Variables & Unknowns  Weather  Condition of participants  Ankle-biters

12 Prevention Strategies Public Health Model  Primary  Secondary  Tertiary

13 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

14 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

15 Tertiary Prevention Strategies  Definition –Treatment of illness or injury –Rehabilitation of illness or injury  Examples –Emergency room transfer –Hospital admission –Rehabilitation center

16

17  Communications  Transportation  Fluids & fuel  Equipment  Supplies  Staffing  Medical & race records  Medical protocols  Medical precautions  Adverse event protocol Race Preparation Areas  Competitor safety  Preparticipation screening  Hazardous conditions  Competitor education  Impaired competitor policy  Race scheduling  Start time  ER notification  Course setup

18 Competitor safety  Athletes' safety first  Sponsor & TV conflicts  IAAF Temp Rule

19 Hazardous conditions  Normal prudent behavior –Suspended by athletes in competition  Raise risk beyond inherent risk of activity –Heat –Cold –Traction –Wind –Windchill –Lightning

20 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?

21 Hazardous conditions  Alternatives –Alter –Postpone –Cancel  Publish protocol in advance  Announce risks at start  Volunteer safety

22 Threats to Runner Safety  Lightning –Hear it, clear it –30:30 rule  30 seconds  30 minutes

23 Heat & humidity  Unexpected increases  Lack of acclimatization  Excess fluid consumption

24 Event Modification Guidelines WBGT = 0.7 wb + 0.2 bg + 0.1 db ActionMilitary GuideACSM Road Race Youth Soccer Cancel >90 F >82 F>82 or Alt schedule Curtail>88 F (<12 wks) >73 F - Free substitution Extreme caution >85 F (<3 wks HA) >73 F>73 F - Shorten games Caution>78 F>65 F>65 F - Quarter breaks, Fluids Normal risk<65 F

25 Temperature - Humidity Graph Exertional Heat Stroke Risk

26 Cold & wet conditions  Increase hypothermia –Especially slower runners  Inadequate metabolic heat

27 Race Cancellation  Environment hazards  Threat of terror

28 Terrorist threats  Establish policy in advance  Enlist local authorities for advice  Integrate into local security plans

29 Liability considerations  Lawsuits in football –Heatstroke  Lawsuits in road racing –Hyponatremia –Wrongful death

30 Is cancellation really that bad...  If it saves a life or decreases morbidity?  Family test –What would you want if your child was entered?

31 Competitor Education  Safety measures  Risks of participation  Fitness requirements  Hydration –Hyponatremia risk  Nutrition  Finish(ing) strategies  Volunteer identification –Red color shirts –Vests –Hats

32 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%

33 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

34 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?

35 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

36 ER Notification  Hospitals near course –Date & time –Course closure –Injury evacuation plan –Expected casualties

37 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

38 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?

39 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

40 Start Finish 2001 TCM Course Map

41 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

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

43 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

44 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"

45 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

46 Rolling Aid at ‘96 Olympics  Medical equipped van

47 Course  First response teams –Motorcycles or bikes –Automatic defibrillators –First aid equipped  EMT trained runners –Phone –CPR –AED?

48 Course Closure  Trailing vehicle –Marked –"Official" end of race  13 min per mile pace –Chip start lag

49 Finish Area Layout  Medical location  Ambulance access  Runner flow  Fluid access  Shelter  Ambulance support  Well finisher shelter  Dry clothes shuttle

50 Finish area map Medical area  Triage –Chute triage  Watch for WC's –Post-chute triage –Area triage  Sweep teams –Bus drop –Family info/waiting tent Elite

51 Finish Area - Boston

52 Finish Area  Field hospital –Major aid station –Subdivisions  Triage  Intensive medical  Intensive trauma  Minor medical  Minor trauma  Skin  Medical records

53 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

54 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

55 Transportation  TCM finish area transportation –Access care in finish area –TCM protocol  Wheelchair  Manned carries  Assisted walk –Access tertiary care  Ambulance  ALS

56 Communications  Type –Phone  Portable cellular or digital  Hard wire –Hand held radios –Ham radio network

57  911 –Any volunteer –Summon ambulance Communications  Locations –Start –Course  Aid stations  Pick-up vans  Course spotters  Ambulance  Other

58 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

59 Communications  Finish area –Central dispatch for course –Field hospital  Phone –Triage teams  Hand held radios

60 Fluids & Fuel  Type –Water  Individualize intake recommendations  Risk of too much –Carbohydrate-electrolyte solutions  > 45 minutes beats H 2 O –High carbohydrate foods

61 Fluids & Fuel  Location –Start –Aid stations –Finish area  Post-chute area  Medical tent

62 Fluids & Fuel  Amount available per runner –6-12 ounces every 20 minutes  Available vs consumed –Double for start & finish  Food –Athletes' preference –Sponsors' stock

63 Fluids & Fuel  Publish in advance –Fluid types –Food types –Locations

64  Defibrillator  Tubs –Rubbermaid  Fans  Back boards  Lights  Portable sink  Toilet  Ice chest Equipment  Shelter –Tents –Vehicles –Buildings  Security fencing  Cots, chairs, tables  Heating & cooling equipment  Generator

65 Supplies  Medical  Trauma  IV fluids –First liter - D 5% NS –Second liter - NS

66 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

67 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

68 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

69 –Physical Therapists –Athletic Trainers –First aid personnel –Non-medical assistants Staffing  Personnel –Physicians –Acute care nurses  ICU  CCU  ER –Paramedics –EMT's

70 Staffing  Location –Start –Course –Finish

71 Staffing  Course aid stations –Physician –RN –EMT

72 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

73 Staffing  Finish area –Numbers  Base on peak injury rate –Qualifications  Base on injury type –Physicians  FP  ER  Critical care

74 Levels of Care for Road Races  National Sports Medicine Institute of UK –Bronze –Silver –Gold

75 Bronze  First aid leader –Ability to contact EMS  No defibrillator on site

76 Silver  Paramedics or physicians or nurses  Ambulance coverage  Treatment centers on site  Defibrillator on site  Communication control center  Plus Bronze

77 Gold  Medical Director  IV capability  Onsite lab analysis  Plus Bronze & Silver

78 Notify runners in race entry materials  Based on available care –Bronze, silver, or gold –Decide on race entry

79 Sharing Race Data  Evidence based staffing ratios –Develop based on race data –Base on environment –Accumulated race injury data  Individual race data  National registry

80 Medical & Race Records  Document care  Calculate incidence of casualties  Project future needs  Research  Entrants, starters, finishers, gender  Document environmental conditions

81 TCM Medical Record

82 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

83 Medical Protocols  First aid –Do no harm –Stay within training level

84 Collapse Site Before finish line  Bad sign –Essential organ system not functioning  Usual problems –Heat stroke –Cardiac arrest –Hyponatremia –Rhabdomyolysis –Insulin shock –Anaphylaxis

85 Collapse Site After the finish line  Better sign  Etiology –Muscle pump is gone –Vasovagal orthostatic syncope –Dehydration  Usual problem –EAC

86 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

87 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

88 Access to Downed Runners

89 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?

90 Exit routes from course to medical care  Urban vs rural vs wilderness access  Ideal entry & exit in direction of runner flow

91 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%

92 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

93 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 –Statistics for other races

94 Adverse Event Protocol  Notify Medical Director  Do not discuss  Controlled press release

95 Family Information & Communication  How to communicate –A medical emergency with a runner  Family & friends  Coaches & agents  Media

96 Considerations & Constraints  Ethics  Confidentiality  Consent

97 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

98 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

99 Post-race Review  What went right? –Most everything  What went wrong? –Identify  Proposed changes –Make it better

100 New Medical Developments

101 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

102 Defibrillators  Types available –Automatic defibrillators (AED) –Manual defibrillators  Locations –On site –On course  AED’s on bikes expand range of care

103 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

104 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

105 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

106 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

107 Symptoms /Signs  Early –Lightheaded –Dizzy –Nausea –Headache  Severe  Progressive  Middle –Vomiting –"Puffy" –Muscle cramps –BP, HR, RR normal –"Impending doom" –Dyspnea –Confusion  Late –Ashen, gray appearance –Prolonged seizure –Obtundation

108 Hyponatremia Solutions  Education runners –Replace sweat losses –Forget "drink as much as you can"  Decrease water stops to every 3 K –Break down extra large field stops at 4 hour plus pace  "Myth" information –Sports drinks do not prevent  Educate volunteers  Measure Na + on site

109 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

110 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

111 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

112 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

113 Race Specific Recommendations  By environment –Hot, humid –Hot –Cool –High altitude

114

115 Summary  Audit your race  Emergency care  What if...? –Its too hot –Its too cold –Someone dies –A car crashes the course  Think runner safety

116 Thank you!

117 rober037@umn.edu


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