Mass Participation Endurance Event Coverage


The mission of event medical coverage is to ensure a safe event for participants and event staff and to provide medical care when needed during the event. Secondarily, this coverage protects the community where the event is staged from undue stress to the emergency response system. Planning, organization, and execution are the most important factors in fulfilling this mission. The medical director is responsible for overseeing this process. The need for this type of coverage is growing and becoming more complex. This chapter will outline medical coverage for large mass participation running events with the focus on marathons. Scalability of coverage for shorter races and for small participation fields will be implied. Although medical coverage of triathlons, ultrarunning events, and off-road obstacle course events have a similar mission, the differences in logistical concerns, risks, and preparation merit a different discussion than road running events.

The number of marathon finishers rose dramatically from 1976 through 2000. There has been a slow increase since with a trend toward a plateau (see Fig. 5.1 ). There are on average 470,000 marathon finishers per year since 2000. The vast majority of these finishers are recreational runners and have varying degrees of experience and preparation. There exists a likelihood for injury and illness in this population. Elite runners comprise a small fraction of marathon participation and, in general, are rarely seen in medical tents. There were an estimated 1100 marathons and 2800 half marathons in the United States in 2016. The largest seven races in the United States in 2016 had greater than 19,000 finishers, while other events such as Chevron Houston Marathon stage a half marathon with the marathon for a combined participation of nearly 20,000. The largest eight half marathons in the United States in 2016 had greater than 18,000 finishers. Additionally, the number of half marathon finishers has tripled since 2004 and is roughly four times that of marathon finishers (see Fig. 5.1 ). These factors create a need for medical care during endurance running events.

Fig. 5.1, Marathon versus half marathon growth. The growth of the half marathon has dramatically increased since 2008 while marathon participation has leveled off since 2010.

As races increase in size so will the medical encounters that occur. Even if the encounter rate remains low, the absolute number of encounters will increase as participation increases. A half marathon held simultaneously with a marathon can reduce overall encounters during a marathon while still allowing participation. This has been shown to be true at the Houston marathon as well, where encounters for the half marathon are typically half as many as the marathon even though participation in the half marathon is significantly greater than the marathon.

Communities may sustain significant impact with large races. This is an important consideration when large events are held in small communities or in communities with limited resources for emergency response. However, one study estimated that marathons may have a net positive effect on community mortality on the day of the event.

Community resources can be stretched or even exhausted if risks are actualized such as on a hot day. Medical coverage of such events should be commensurate with the size of the race and the apparent risk to limit community impact. Event medical coverage has expanded and has become more sophisticated. This has been driven by an increase in race budgets, advances in technology and by collaboration within the race medicine community. Point-of-care blood testing, portable automated external defibrillators (AEDs), and electronic medical records are examples of how technologic advances have influenced event medical coverage. Organizations such as the International Institute for Race Medicine promote education and collaboration within the race medicine community by making best practices available worldwide. Best practices rather than absolute numbers and quantities are recommended, which allows for scalability in races of varying sizes and means. Event sponsorship and funding is a large influence on the medical planning as well. Well-funded events can afford more resources and enact more treatment onsite. Events with less funding may need to triage and transport medical encounters, which obviously places more burden on the community.

Additionally, social and political influences have imposed additional risk on mass participation events such as marathons. This has affected several races worldwide (Sri Lanka 2008, Pittsburgh 2010, Boston 2013). Most major race organizers consider these risks in the planning and preparation for their events. Collaboration with local, state, and federal agencies to identify and minimize risks is now an accepted part of staging an event. Contingency planning is prudent for race organizers to consider. Evacuation plans for start line, finish line, and runner reunion venues as well as the course itself are important to have in place. Medical directors should be included in the decision-making as part of this public safety effort.

Another factor in developing medical coverage for an endurance road race is the type of course that is used. There are two types of courses. A closed-loop course is generally easier to prepare for given the more confined footprint. This makes coverage simpler as the likelihood of the event passing through multiple municipalities is less. Moving personnel and assets within the course perimeter is also likely to be easier on a closed-loop course.

The linear nature of a point-to-point course may make coverage more challenging. The course may run through multiple communities. This would necessitate dealing with their respective agencies, which can create an additional administrative burden. It requires planning and meeting with each of these entities to ascertain and comply with their concerns. There is also greater distance between the start and finish, which makes restaging personnel and equipment from the start of the race to later stages of the race more difficult. However, the additional municipal alliances may also strengthen the amount of resources available to assist and improve access to and transportation from the course.

Pre-event Planning

A medical director is essential to the process of developing, implementing, and reviewing medical coverage. This individual must work with the event staff to establish parameters for coverage. This will in essence be the mission statement for the medical team. A budget should be developed and adhered to. This budget should be sufficient to support the needs and objectives of the medical plan. The medical plan is established inclusive of an estimation of potential risks to the event. These risks should be discussed to determine which risks can be managed within the event by the medical team and the event staff. If there are risks that are beyond the capabilities of the event and the medical team, it must be determined if partnership with the community is a viable option to mitigate these risks. It is also important to clearly state in writing under what circumstances the event will be modified, postponed, or canceled. This should be available for all participants to see, preferably on the event webpage. Failure to do this leaves the event subject to unnecessary criticism and liability.

The medical director must also build a team to help develop and complete the many varied tasks of medical planning. He or she must also work with community agencies to establish terms of collaboration within the normal functioning event and during extraordinary circumstances.

It is vital for the medical director to be organized. Time management skills and visionary thinking are very useful traits. Understanding the nature of the event and its interaction with the community will ensure that the coverage is appropriately sized and implemented. Leadership skills such as insightful judgment, calm demeanor during stressful situations, willingness to delegate and entrust details to assistants, and humility will create cohesiveness and loyalty within the medical team. The medical director cannot do the job in isolation. The effective delivery of medical care to a mass participation event is a team endeavor orchestrated by a strong leader.

In large events, the medical director is not likely to be a care provider. Team organization is often partitioned into functional areas (see Fig. 5.2 ). Prior to the event, the medical director and his designated area captains will work with event staff to develop the medical plan and to oversee volunteer recruitment. Delegation of tasks to captains or assistants will make preparation more thorough and keep adverse situations to a minimum. On the day of the event, the medical director will take on an oversight role and serve as a liaison between community agencies, the medical team, and event staff. Crises will inevitably occur in each event, and the medical director oversees this management. Objective thinking, decisiveness, and clear communication are critical to manage crises when they arise. If these situations involve medical matters or public safety, the medical director will work with public relations to convey a clear and succinct message of the crisis and how it will be managed. Following the event, the medical director will organize a debrief to analyze the performance of the medical team in carrying out the medical plan. This will be documented in a postevent report.

Fig. 5.2, Houston Marathon Committee Medical Team Organizational Chart: This organizational chart is an example of how a medical team might be structured to provide medical coverage of a mass participation endurance event.

Mission Setting

Goals and objectives can be established once several factors are considered. Event priorities and resources need to be ascertained. The race distance and the number of participants as well as the personnel and resources available will determine what method of coverage is appropriate. Additionally, community size and ability to assist or support will be a factor to consider. Best practices should guide how a race sets up medical coverage. This will ensure an appropriate scale for the event and ultimately sustainability.

There are two basic types of coverage that can be provided. If resources allow, the “triage and treat” method is recommended, as this can be efficient and spare the community from unnecessary burden to local emergency departments. All non–life-threatening conditions can be treated on site. Cardiac emergencies and significant trauma (fractures or head injuries) will always necessitate transport to the nearest hospital.

The other method is “triage and transport.” In this method, almost all care is shunted to community emergency departments. This is best utilized if medical care at the event is limited by lack of medical staff or assets. In a small event, this may not pose a significant burden, but in a large event, particularly with inclement weather, the casualty burden may be large. This method should always be discussed with community leaders, as it may be too much for the community to endure. In this case, the event should be downsized or moved to a different locale.

Medical directors may face some of the most difficult challenges in preplanning work associated with event organizers and their disposition regarding medical coverage. Having a written policy on race cancellation and modification is important. In the event of unfavorable conditions, the medical director must be able to initiate a discussion of altering the race or even not starting the race with event organizers. There are resources available to help both race directors and medical directors recognize and address the risks associated with mass participation events.

The International Institute for Race Medicine is a collaborative of medical directors from around the world whose mission is to provide education and support for those responsible for medical care at mass participation events. The National Center for Spectator Sports Safety and Security (NCS4) also provides education and training on matters relevant to mass participation events.

It is advisable for medical directors to review historical data from earlier renditions of the event, which may be useful in understanding and planning for appropriate numbers of staff and equipment. Furthermore, the number of participants and the length of the race as well as the time of year and the usual weather are reliable indicators of the types and numbers of medical encounters. A larger participant pool usually results in more medical encounters. The length of the event may exacerbate or mitigate this. The author's experience is that the marathon has more encounters and generally more severe encounters than the half marathon.

Medical risk and the requirements to provide coverage are often underestimated. Race directors may not be aware of the health concerns and risks of endurance events and the magnitude of risk with large event participation. The restraint that medical coverage may impose on event planning and size is often unwelcome and/or ignored. An event that exceeds the ability of a medical team to provide sufficient and timely care escalates risk. Medical directors must work with race organizers to set objectives for medical coverage. Education and persistent guidance with race organizers is required and is the first step toward sufficient medical coverage. Even with cooperation of race organizers, budgetary constraints may come to bear on the coverage that can be provided.

Medical Legal

Liability insurance is needed for medical volunteers. Even if Good Samaritan laws exist, liability coverage is prudent. This may be a subset of liability insurance for the event as a whole. Basic road race insurance may not cover medical personnel. The individual malpractice policies of medical professionals may also exclude coverage outside of the usual practice setting of the professional. Historically, medical liability coverage was not consistently or clearly provided, and often healthcare professionals incorrectly presumed that Good Samaritan laws would protect them. Fortunately, there are more options for race organizers now than a decade ago when looking into broader liability coverage for their medical team, but it is prudent that organizers do not assume that coverage is part of the typical liability policy.

Confidentiality protocols should be developed for participants treated in the medical area and on the course. Any questions concerning runners seen for medical treatment should be directed to the medical director and the public relations team. Requests from the media for encounter statistics after the race are common but should be carefully stated so as not to violate confidentiality. Sensitive information about individual cases, particularly if hospital transport or resuscitation was required, must be dispensed with the utmost discretion.

Record keeping is important for short and long term. In the short term, it provides data for furthering race medicine, which at this point remains rudimentary. In the long term, records may be useful in the event of liability claims.

How records are kept can vary. Paper records are inexpensive but need to be stored safely and securely. Furthermore, data extraction from paper records is tedious. Electronic records allow for easy data analysis but present more complex confidentiality concerns, and this type of documentation is costly. It necessitates having team members who are proficient in information technology to be effectively implemented and maintained. Procuring the devices used for electronic record keeping will require budgetary and logistical planning.

Medical Assets

Equipment needed for medical coverage will depend on the medical plan that will be implemented. This equipment generally includes supplies, durable medical equipment, and ancillary equipment. The budget for the medical team and the size of the race are primary determinants of the sophistication of this equipment and how these items are acquired. Durable assets that are used from year to year may be reasonable to purchase. These include blood pressure cuffs, blankets, cots, wheelchairs, rolling stretchers, aid station tents, and bike medic bags. Some of these items could also be rented or acquired via loan. Ancillary equipment such as storage bins and rolling racks are best to own, as they allow any equipment and supplies used every year to be safely stored and organized. Perishable supplies such as ice, oxygen, IV fluids, water, and other hydration products will need to be purchased yearly or received via donation. A medical team sponsor is ideal for providing these items.

Infrastructure needs such as tables and chairs, partitions, signs, drapes, plumbing, and electrical equipment are probably best provided by the vendor that provides for the event with the cost assigned to the medical budget.

More advanced equipment such as AEDs, cardiac monitors, portable blood analyzers, radios, and computers are too expensive and unnecessary to own and should be rented or acquired via charitable donation or in-kind sponsorship.

All supplies and equipment should be inventoried. Ideally, there is a member of the medical team tasked with inventory and cleaning and maintenance of equipment. A storage facility with climate control for all equipment that is owned is recommended.

Team Members

There should be a designated leader or captain for each major area within the medical team. The main tent and the field each should be directed by a physician who oversees other functional areas within those arenas. Any area that requires advanced planning for direct patient care or support of the medical team should have a designated captain. Physicians and nurses or nurse practitioners are obvious choices as team members whether it be in the main tent or the field tents. Physician assistants, athletic trainers, and physical therapists can fill several positions. Medical students, athletic training students, and other students can fill roles that are supervised or require less responsibility. The numbers of physicians and ancillary medical personnel will vary depending on the size and length of the race, the typical weather and encounter rate, and the type of care being delivered at the race. More advanced medical providers and/or varied levels of medical providers enable more advanced care at the event and may reduce the numbers of transfers to local hospitals.

Collaboration with Community Resources

The local fire department or emergency management system is helpful as an augmentation of medical services and as backup in the event of unusual circumstances. The police department is important for traffic control and course security. In larger events, other agencies such as the FBI, Homeland Security, or the Office of Emergency Management will provide background support and also be in position to oversee contingency operations.

This may also include a Unified Command Center (UCC), which functions on race day to monitor the event and the surrounding areas. Public safety, in general, is the mandate of this unit. This center has representatives from all major agencies involved in the event, including local, state, and federal organizations that may be assisting with the event management. The purpose of this facility is to create an efficient and uniform approach to event and community safety. With all functioning agencies in the same room, communication is faster and more accurate. Response times to unusual or emergent situations are reduced, and the response to such events is more coordinated.

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