Medical Supervision of Mass Sporting Events

Abstract

Physical inactivity is one of the major modifiable risk factors for non-communicable diseases (NCDs) and universal prescription guidelines for physical activity for all individuals include engaging in >150 min of moderate- to high intensity physical exercise weekly. Participation in mass community-based sporting events including park runs, road races (distances vary from 5 km to ultra-marathons), cycling events, swimming events, and events combining endurance sports e.g. triathlon is increasing, and the profile of participants at these events is also changing, with increasing numbers of older individuals and female participants. There is a known risk of medical complications during moderate- to high intensity exercise, and this risk varies according to the “risk profile” of the individual. These medical complications during exercise can vary from minor to severe life-threatening and also result in death from cardiac arrest and other causes. Medical staff, that are responsible for participant safety at mass community-based sporting events, need to be aware of the risk of medical encounters at events, causes and risk factors associated with medical encounters, and can design and implement strategies to reduce the risk of medical encounters at these events. In this Chapter we review the risk, definition and classification of medical encounters at mass community-based sports events, highlight the exercise benefit-risk paradox, and outline a step-wise plan to reduce the risk of medical encounters at mass community-based sports events. We explore the potential role of pre-event medical screening for mass sporting events and formulate a plan to implement medical care on race day for mass community-based sporting events. Finally, we present guidelines to minimize the potential negative effects of environmental stress, including air quality at mass community-based sporting events.

FormalPara Learning Objectives

• 1. Understand and estimate the risk of medical encounters at mass community-based sports events.

• 2. Be able to define and classify medical encounters at mass community-based sports events.

• 3. Understand the exercise benefit-risk paradox.

• 4. Implement step-wise planning to reduce the risk of medical encounters at mass community-based sports events.

• 5. Understand the potential role of pre-event medical screening for mass sporting events.

• 6. Plan and implement medical care on race day for mass community-based sporting events.

• 7. Develop guidelines to minimize the potential negative effects of environmental stress, including air quality at mass community-based sporting events.

• 8. Be able to document medical encounters at community-based sporting events.

1 Introduction

Non-communicable disease (NCDs) of lifestyle are the number one cause of death worldwide and are currently responsible for >70% of all deaths. Physical inactivity is one of the major modifiable risk factors for NCDs. Universal prescription guidelines for physical activity for all individuals include engaging in >150 min of moderate- to high intensity physical exercise weekly.

• Brisk walking, jogging, running, cycling, swimming are common endurance exercise activities that are prescribed to individuals.

• There are an increasing number of sports events around the world where large numbers of individuals engage in organized endurance sports—these can be considered “mass community-based sporting events”.

• Mass community-based sporting events include park runs, road races (distances vary from 5 km to ultra-marathons), cycling events, swimming events, and events combining endurance sports e.g. triathlon

• There are data indicating that the profile of participants at these events is changing, with increasing numbers of older individuals and female participants.

There is a known risk of medical complications during moderate- to high intensity exercise, and this risk varies according to the “risk profile” of the individual. These medical complications during exercise can vary from minor to severe life-threatening and also result in death from cardiac arrest and other causes. Medical staff, that are responsible for participant safety at mass community-based sporting events:

• 1. need to be aware of the risk of medical encounters at events, causes and risk factors associated with medical encounters, and

• 2. can design and implement strategies to reduce the risk of medical encounters at these events.

1.1 Risk of Medical Encounters at Mass Sporting Events

• In a recently published international consensus paper, general definitions and more specific definitions of medical encounters (by severity, timing and type) were outlined [1].

1.1.1 General Definitions

A mass community-based endurance sports event is defined as

• “a planned and organised endurance sports event, usually with > 1000 entrants (recreational and/or elite), at a specific location, for a specific purpose, and for a defined period of time (single day/stage or multiple stages/several consecutive days)” [2, 3].

A “community-based” event is typically planned and organised by a community sports organisation with a committee that includes a race director. We refer to “mass participation” as a mass-gathering with >1000 race entrants [2, 3], but also recognise that events of a smaller size (<1000 race entrants) can be managed and collect data.

An “endurance sports event ” is an event that includes one or more of the following sport types:

• (a) distance running

• (b) cycling

• (c) swimming

• (d) triathlon

• (e) biathlon

• (f) duathlon

• (g) canoeing/kayaking

• (h) cross country skiing

• (i) mixed ultra-endurance events

• (j) other similar activities that combine any of these disciplines or function with more than one athlete as a team of entrants.

The medical team is defined as

• the “team responsible for the medical care during the event and is made up by officially designated medical staff (medical physicians, emergency medical and basic first aid providers, registered nurses, physiotherapists, athletic trainers, and others), typically led by a medical director (or equivalent)”.

1.2 Definitions of Medical Encounters

Athletes participating in endurance events may develop a “medical problem” during the event, and this “medical problem” may or may not be reported by the athlete to the medical team providing medical care at the event. Therefore, not all medical problems are reported by the participants.

• A “non-reported medical problem” is defined as “a medical problem experienced by an athlete participating in an event, where the athlete decides to either seek no assistance, or seek assistance outside of the event medical team”.

The term “medical encounter” is used as the standardised term to define any reported “medical problem” at an event, including both illnesses and injuries. Medical encounters can be classified by severity into:

• (a) minor,

• (b) moderate,

• (c) serious/life-threatening,

• (d) sudden cardiac arrest,

• (e) sudden cardiac death, and

• (f) sudden death.

The detailed definitions of medical encounters as well as the definitions of medical encounters classified by severity are listed in Table 29.1 and depicted in Fig. 29.1. A medical encounter at a sports event can occur at different times during or following the event, and documenting the timing of the encounter is clinically important. Three time periods for the timing of a medical encounter have been defined:

• during the event (from the official start to completion of the event).

• immediately post-finish (from the time the athlete completes the event to 1 h after the athlete completes the event).

• delayed presentation (between 1 and 24 h after the athlete completes the event).

Table 29.1 Definitions of medical encounters and medical problems. (Reproduced with permission from [1])

Fig. 29.1

Classification of medical encounters by severity. (Reproduced with permission from [1])

1.3 The Exercise Benefit-Risk Paradox

Moderate- to high-intensity regular physical activity, including distance running, is widely recommended for health [4], there is also equally strong evidence that moderate- to high-intensity exercise acutely, and transiently, increases the risk of a range of acute medical complications [5, 6], including acute myocardial infarction and sudden cardiac death [7,8,9,10,11].

• Exercise benefit-risk paradox 1: Regular moderate-to high-intensity physical activity is both associated with substantial long-term health benefits, there are also potential negative health consequences during an acute exercise session [7,8,9,10,11].

• Exercise benefit-risk paradox 2: The greatest health benefits of regular exercise are frequently observed in

  • sedentary individuals that transition to becoming physically active, and

  • patients with known chronic disease [12]

but these groups also have a higher risk of potential acute medical complications during an exercise session [7, 9, 13,14,15,16].

It is important that the exercise benefit-risk paradoxical observations need to be placed into perspective. Data from >30 meta-analyses unequivocally support the recommendation that, from a population perspective, the participation in regular physical activity in these two groups of individuals still far outweighs the potential negative health consequences of an acute exercise session [7,8,9, 14, 15].

2 Planning to Reduce the Risk of Medical Encounters at Mass Community-Based Sports Events

Race medical teams/race medical directors have a responsibility to reduce the risk of medical encounters at mass community-based sports events. Three pre-race planning and implementation steps are important to reduce this risk:

• 1. Quantify the risk of acute medical encounters during exercise.

• 2. Identify causes, risk factors and the frequency of “at-risk” individuals for medical encounters.

• 3. Design and implement measures to reduce the risk of acute medical encounters during an exercise session.

2.1 Step 1: Quantifying the Risk of Acute Medical Encounters During Exercise

Physical exercise can trigger acute cardiovascular in both younger and older athletic populations [7, 11, 13, 17,18,19,20,21,22]. The relative risk of an acute cardiovascular event during exercise, compared with sedentary activity, varies from 2 times in young athletes [11] to as much as 56 times in older individuals who are at risk for cardiovascular disease or who have existing cardiovascular disease [7, 11, 16]. The absolute risk of an acute cardiovascular event during an exercise session is consistently reported as being very low (1 in 50,000 to 1 in 200,000 annually) [7,8,9, 11, 14, 15]. The risk of sudden death during mass community-based distance running events such as the half-marathon (21 km) and the marathon (42 km) are well described [11, 17, 23,24,25,26,27,28,29], and there is considerable variation in the reported absolute risk of sudden death during marathons and similar races (between 1 in 30,000 to 1 in 250,000 race entrants); generally this risk is 1 in 114,000 race entrants (calculated cumulative risk) [11] and therefore also reported as being very low.

Besides sudden death during marathon running, sudden cardiac arrest (including non-fatal cardiac arrest) and other serious medical complications can also occur. In Table 29.2, the absolute risk of medical complications during distance running by severity (sudden death, sudden cardiac arrest, serious medical complications, and any medical complication) is summarized [30].

• In comparison to sudden death, the risk of sudden cardiac arrest during a marathon race is 2–3 times higher [11].

• In comparison to sudden death, the relative risk of a serious medical complication at a distance running event such as the marathon is 50–100 times higher than sudden death.

• The absolute risk of any medical complication during a marathon race also varies between 1 in 22 to 1 in 121 entrants, but generally is about 1 in 50 runners.

• The clinical relevance of these data is that in a marathon with a large field of 50,000 runners, the medical staff will, on average, encounter a:

  • sudden death every 2–3 years,

  • sudden cardiac arrest every year,

  • 25 runners that present with a serious medical complication requiring specialized management or hospitalization, and

  • 1000 runners that require medical attention (Fig. 29.2) [30].

Table 29.2 The absolute risk of medical encounters during distance running by severity (sudden death, sudden cardiac arrest, serious medical encounters, any medical encounter)—rates are expressed per 100,000 race entrants and number of entrants per single incident. (Reproduced with permission from [30])

Fig. 29.2

Risk of medical complications, severity and screening continuum—estimated absolute risk (per 100,000 race entrants) of medical complications in distance running events. (Reproduced with permission from [30])

This risk continuum is an important consideration in planning medical coverage at large mass community-based sports events. Providing this coverage is a considerable undertaking and requires careful planning long in advance of the event, recruitment of a large team of specialized medical staff [31], the establishment of considerable infrastructure, and securing sophisticated equipment at race medical facilities to ensure race safety.

Many factors determine the risk of a medical encounter during mass community-based sports events including:

• environmental conditions on race day,

• the course and race distance, and

• the “risk” demographics of the running population (runner experience, runner education, and runners with risk factors for acute medical complications during exercise),

all of which may influence the incidence of these complications at a specific race [31].

2.2 Step 2: Identify Causes, Risk Factors and the Frequency of “at-risk” Individuals for Medical Encounters

The demographics of participants in mass community-based sports events is changing. In the distance running population, demographics changed over the past two to three decades, with almost 50% of current marathon entrants being older than 40 years.

2.2.1 Risk Factors Associated with Acute Cardiovascular Encounters

The most common cause of sudden death or cardiac arrest in older marathon runners is coronary artery disease.

• According to the European guidelines [32, 33], older runners (males >45 years; females >55 years) with one or more risk factors for CVD, and runners of younger age with two or more risk factors for CVD, require medical assessment before engaging in moderate- to high-intensity exercise such as distance running.

• Recently, it was shown that:

  • 10% of Master athletes (mean age 50 ± 9 years) have existing cardiovascular disease, and 64% have at least one risk factor for cardiovascular disease [34].

  • 16.1% of runners reported at least one risk factor for CVD, with 13.4% reporting more than one risk factor with the most common specific risk factors for CVD being males >45 years (15%), high blood cholesterol concentration (5.8%), high blood pressure (4.4%) and a family history of heart disease (4.4%).

• Risk factors associated with an acute cardiovascular complication during an exercise session are summarized in Table 29.3.

Table 29.3 Risk factors associated with an increased relative risk of acute cardiovascular complications during moderate- to high-intensity exercise. (Reproduced with permission from [30])

2.2.2 Risk Factors Associated with Other Causes of Sudden Death and Serious Medical Encounters

There are other causes of sudden death and serious medical encounters during mass community-based sports events that are not related to coronary artery disease, including the following:

• (a) severe fluid and electrolyte abnormalities (mainly hyponatremia)

• (b) acute renal failure

• (c) exertional heat stroke

• (d) other serious encounters

Risk factors for these other non-cardiac encounters should also be considered in an intervention strategy to reduce the risk of acute medical encounters during exercise (Table 29.4). Race participants may have several intrinsic risk factors that can predispose them to serious acute cardiovascular (Table 29.3) or other serious non-cardiac medical complications (Table 29.4) on race day. The risk of a medical complication on race day in the “at risk” runner is also influenced by other extrinsic factors such as

• exposure to adverse environmental conditions (heat and humidity, altitude, pollution),

• the race distance, and

• course characteristics.

Table 29.4 Risk factors associated with an increased relative risk of other serious medical complications during moderate- to high-intensity exercise. (Reproduced with permission from [30])

2.2.3 How Common Are Risk Factors Associated with Medical Encounters in Race Participants?

Over the past two decades, the demographics of the marathon participant shifted to older runners and female runners [13]. There is an increase of >12-fold in overall participation in marathon runners since 1976, with a notable increase in participation in the older age groups (>40 years); in 2015, 49% of all runners completing marathons in the USA were masters (>40 years old).

• The prevalence of risk factors in 21 km and 56 km runners was recently documented through an online pre-participation screening tool, and showed the following:

  • 2.3% of all runners reported known existing cardiovascular disease (CVD)

  • the most common CVD’s were coronary artery disease (0.5%), followed by arrhythmia (0.4%)

  • 1.8% runners reported symptoms that may be suggestive of CVD.

• Four risk categories for medical encounters during participation (very high risk, high risk, intermediate risk and low risk) in participants that underwent screening with criteria, recommended interventions and frequency in runners have been published [35, 36] (Table 29.5).

Table 29.5 Risk categories, clinical categories, and criteria for risk stratification in distance runner entrants. (Reproduced with permission from [1])

2.2.4 Prescription Medication as a Risk Factor for Medical Encounters During Exercise

The use of prescription medication is extremely common among mass races participants (47.2% of runners) and is among the most common criteria identified by the current European guidelines [32, 33], for recommending consulting a physician before exercise. The potential risk of a medical complication during exercise, as a result of prescription medication, can vary greatly and is related to the underlying medical condition for which the medication is prescribed, and the side effect profile of the medication.

Pharmacological agents may be associated with an increased risk of developing medical complications during exercise as follows:

• (a) cardiac arrhythmias [37,38,39,40]

• (b) renal complications including acute renal failure [41], rhabdomyolysis [42, 43]

• (c) gastrointestinal bleeding [44,45,46]

• (d) risk of tendon injuries including acute tendon rupture [47, 48].

• Analgesic and anti-inflammatory medications (AAIM) use is particularly frequent among athletes due to the high injury rate (SAFER VI). A considerable number of runners (15.6%) reported ingestion of pharmacological agents, mainly anti-inflammatory medication (7.8%) and more specifically NSAIDs (4.9%), in the 7 days before or during races is of concern.

• Stimulants such as methylphenidate and dextroamphetamine-AMP, commonly prescribed for the treatment of attention deficit hyperactivity disorder can have severe consequences when exercising for a prolonged period of time in a hot environment. These substances increase the availability of dopamine, masking the signs and symptoms of fatigue, and allowing for a longer duration of exercise. This might lead to elevated temperature in excess of 40 °C and increased heart rate, thus predisposing to exertional heat illness [49].

• Anti-depressants, in particular selective serotonin reuptake inhibitors (SSRIs), have a significant impact on body temperature regulation. Thermoregulation is controlled by dopamine and serotonin. When the neurotransmitters’ balance is impaired, the hypothalamic set temperature could be impacted, increasing the risk of exertional heat illness [50]. Furthermore, SSRIs have been found to reduce the serum sodium concentrations, thus, thirst. This could lead to an increased dehydration during exercise in the heat [51].

• Statins are the most effective and frequently prescribed medications for the management of high concentrations of low-density lipoprotein cholesterol (LDL-C). Inhibition of HMG-CoA-reductase prevents the production of mevalonic acid. Mevalonate is also produced in response to heat stress and an increased production of mevalonate is associated to a greater tolerance to heat at cellular level. Therefore, preventing the production of mevalonate could potentially place an individual at risk of exertional heat stress.

The cardiovascular effects of commonly prescribed substances are extensively presented in another chapter in this book; therefore, readers are invited to refer to that specific chapter (Chap. 28). Nevertheless, some substances are particularly relevant for endurance events participants, for the severe side effects they can have.

2.2.5 Step 3: Design and Implement Measures to Reduce the Risk of Medical Encounters During Exercise

2.2.5.1 Introduction to Pre-exercise Screening

International guidelines to reduce the risk of acute cardiovascular risk during exercise have been developed and implemented by many sports federations [10, 52], and international bodies including the International Olympic Committee (IOC) [53] and the International Paralympic Committee (IPC) either mandate or recommend pre-participation screening [10]. However, currently these screening programs focus mostly on screening younger elite athletes [21, 54, 55], and concentrate almost exclusively on pre-participation cardiac screening (including a resting ECG) to reduce the risk of acute cardiovascular complications.

• In Canada, the Physical Activity Readiness Questionnaire (PAR-Q+) and the Physical Activity Readiness Medical Examination (ePARMed-X+) were developed as primary front-line pre-participation tools for physical activity [56], and are based on a systematic review of evidence (see Chap. 7) [57, 58].

• Similarly, the American Heart Association (AHA) [59] and the American College of Sports Medicine (ACSM) [15] have recommendations for pre-participation screening.

• The European Society of Cardiology together with the European Association of Cardiovascular Prevention and Rehabilitation [32] specifically developed recommendations, by consensus, for the pre-participation screening of masters and leisure athletes.

• The first step in the recommended screening process is a “self-assessment of risk”, and this is based on the American Heart Association (AHA)/American College of Sports Medicine (ACSM) pre-participation screening questionnaire for individuals at Health/Fitness facilities [60] and the PAR-Q [32].

• The European guidelines recommend that this initial “self-assessment of risk” can be conducted by the individual and consists of health information related to:

  • any history of known cardiovascular disease, cardiovascular symptoms, medication use, and other health issues (Sect. 29.1), and

  • known risk factors for cardiovascular disease including male gender, older age, hypertension, smoking, hypercholesterolemia, diabetes or hyperglycemia, and obesity (Sect. 29.2).

Based on the responses to questions in Sect. 29.1 (any one positive response to a question) and Sect. 29.2 (presence of ≥2 risk factors), it is then recommended that individuals undergo a thorough medical assessment by a qualified physician before participating in moderate- to high-intensity exercise, such as distance running [32].

• In one study, the ESC/EACPR screening guidelines have been applied to adult participants >40 years of age, who participated in the National Health and Nutrition Examination Survey (2001–2004) [61]. Based on “self-assessment of risk”, approximately 95% of women and 93.5% were advised to consult a physician before embarking on exercise [20].

• In two other studies, full pre-participation screening incorporating medical histories, physical examination and special investigations (electrocardiography, echocardiography and blood tests) effectively identified middle-aged athletes with risk factors of cardiovascular disease (CVD) [62, 63].

However, neither study identified the links between the “risk self-assessment” and the outcome of the full screening. Although ideal, full screening of every leisure athlete older than 45 years who participate in large community events would not be cost-effective or logistically feasible.

2.2.6 What Is the Role of Pre-event Medical Screening for Mass Sporting Events?

A potential strategy to reduce the number of medical encounters is the development of an online pre-participation “self-assessment of risk”, as currently recommended by European guidelines, during pre-race registration in community-based mass sports participation (distance running) event. International pre-exercise screening recommendations in leisure athletes [15, 32, 33] are currently not applied at community-based mass participation events and there are few data that these guidelines are indeed appropriate for pre-event medical screening of leisure athletes.

• In one study involving >15,000 recreational distance runners, the pre-race screening tool (Table 29.6) identified that over 30% of entrants for this event would, according to current European guidelines, require referral for a full medical assessment prior to participation in the distance races (moderate-to-high intensity exercise).

Table 29.6 Summary: main elements of the pre-race medical screening tool. (Reproduced with permission from [1])

2.2.7 Does Pre-event Screening Reduce Medical Encounters?

International medical associations have produced consensus-based recommendations/guidelines to screen individuals prior to engaging in moderate- to high-intensity exercise [15, 32, 33, 56, 59]. Pre-screening must be accompanied by an individualized educational intervention program.

• In one recently published study, such a pre-race screening and educational intervention was shown to be associated with the following [36]:

  • A reduction in overall medical encounters of 29% (21.1 km race—reduction by 19%; 56 km race—reduction by 39%).

  • A reduction in serious life-threatening medical encounters by 64%.

  • Registration numbers increased in the intervention period, and overall % race starters (81.5%) were similar in the control (81.0%) and intervention period (81.8%).

  • The wet bulb globe temperature (WBGT) was similar in the control and intervention period.

2.3 Planning Medical Care on Race Day for Mass Community-Based Sporting Events

2.3.1 Pre-race Planning

• Race organizers should appoint a Medical Director as head of the Medical Team.

• The Medical Director is ultimately responsible for all health care services provided at all official sites, venues and accommodation areas.

• The Medical Director is in charge of the overall coordination of medical organization and represents the Medical Team of the Organising Committee.

• The Medical Director’s responsibilities include:

  • Ensure recruitment and supervision of the various medical personnel.

  • Design a comprehensive health care system, making sure that adequate facilities, supplies and equipment are available for medical care at all official sites.

  • Co-ordination of community medical resources, including emergency transport services, emergency room(s) and hospital admissions.

2.3.2 Planning Health Care Services on Race Day

The scope of health care services on race day includes:

• (a) critical care,

• (b) first-aid,

• (c) treatment for environmental illnesses, and

• (d) general medical problems associated with endurance events.

The extent of services depends on the location, duration and type of competition, as well as the type and number of participants expected, and the nature of the injuries or illnesses which are predictable.

Health Care Services include, but are not limited to the following:

• Adequate facilities available for medical services to cover all people and all competition sites;

• Provision of primary and emergency care to all above mentioned people at the various venues and areas of the event, at no charge to all eligible persons;

• Provision of other medical support services needed to ensure the safety and health of the aforementioned, and of the spectators;

• Coordinating service with the hospital network and emergency services;

• Supervision of environmental, meteorological health and safety at all sites.

3 Guidelines to Minimize the Potential Negative Effects of Environmental Stress, Including Air Quality

3.1 Heat Stress

The risk of heat illness increases above 21 °C (70 °F) and 50% relative humidity. The WBGT, which measures the combined thermal stress from the wet bulb (WBT), dry bulb (DBT), and black globe (BGT) thermometers has been widely used to assess environmental heat stress. Several thermal stress indexes have been developed through the years and provide with further information, like the Physiologically Equivalent Temperature (PET), the modified PET (mPET) and Universal Thermal Climate (UTCI) indexes.

The thermal index and colour coded flags to indicate the risks of thermal stress are:

BLACK FLAG:	Extreme Risk—WBGT >28 °C (82 °F), PET >35 °C
RED FLAG:	High Risk—WBGT is 23–28 °C (73–82 °F), PET is 29–35 °C
YELLOW FLAG:	Moderate Risk—WBGT is 18–23 °C (65–73 °F), PET is 23–29 °C
GREEN FLAG:	Low Risk—WBGT is below 18 °C (65 °F), PET is 18–23 °C
WHITE FLAG:	No Risk for heat stress but increasing risk for hypothermia when—WBGT is below 10 °C (50 °F), PET 18 °C.

A recent publication [64] has clarified and established the relationship between environmental parameters on race day and the risk of not completing the race due to excessive heat stress. This relationship has been described through the following formula (t, temperature):

$$ \%\mathrm{Do}\ \mathrm{Not}\ \mathrm{Finish}=-0.59\times {t}^{{}^{\circ}}\mathrm{C}+0.02\times t{}^{\circ}{\mathrm{C}}^2+5.75 $$

In general, particularly considering endurance events, better performance and less adverse results are obtained when the environmental conditions are going to improve, rather than worsen, during the event. As an example, in hot environmental conditions, start times would be better set for late afternoon rather than early morning (increased thermal stress in sunny morning), for road racing.

3.1.1 Air Quality

• The health impact of living and exercising in highly polluted environments have been widely demonstrated in the scientific literature [65,66,67].

• Therefore, the monitoring programmes of local pollution and pollen ratings before and during an endurance event should be implemented.

• Daily average of main pollutants (NO₂, O₃, particulate matter (PM2.5, PM10), CO) should be provided, before and for the entire duration of the event.

3.2 Medical Facilities on Race Day

Medical services must be available on the race course, and available to all participants. The medical areas should include:

• (a) a pre-starting line treatment area;

• (b) medical first-aid teams along the course, ideally every 5 km or located in strategic positions;

• (c) a triage/emergency area at the finish line;

• (d) the main treatment area at the finish line (with ambulances stationed near-by).

Advanced life support emergency ambulance with AED coverage should be available along the whole course, up to the finish line. The first-aid teams should evacuate all injured or sick athletes from the course at the earliest time, and transfer all of them to the main treatment area at the finish line. The evaluation and treatment of environmental and exercise related medical problems like dehydration, hyperthermia, hypothermia, exercise associated collapse, and problems associated with road racing, including allergic responses such as anaphylactic shock, hives, asthma exacerbation, and diabetic insulin reactions is of notable importance.

4 Aid Stations

• Aid stations should be located every 5 km or at pre-defined medical points along the course.

• AED and first-aid kits shall be available.

• Equipment and supplies for obtaining vital signs, performing BLSD and ACLS should be available at major on-course medical stations.

5 Roving Medical Vehicles and Critical Care Teams

• Roving medical vehicles and mobile medical aid, though they are impeded by runners, offer the best solution for rapid response to a collapsed athlete on a road course.

• The use of fully-equipped ambulances on the course is advantageous and increases the medical response capabilities.

• Equipment and supplies for obtaining vital signs, performing Basic Life Support—Defibrillation (BLSD) and Advanced Cardiac Life Support (ACLS) should be available in the roving medical vehicles.

6 First Response Teams

• AED-equipped motorcycles or bicycles have rapid access to collapsed athletes with potential cardiac arrest.

• Operators must be trained in the use of AED, and the team must be integrated with the local emergency medical system.

• Several teams must be assigned along the course to follow the main pack and separated by 2–4 km giving rapid access to most runners.

• First response teams should be prepared to evaluate and treat cardiac arrest, exertional heat stroke, hyponatremia, diabetic insulin shock, status asthma, and exercise-or allergic anaphylaxis.

7 Finish Line Area

It has been widely demonstrated that the number of medical encounters in the final quarter of the race is significantly higher in respect to other segments. Therefore, in the last 2 km of the course, medical staff and supplies should be increased. Usually at this stage of the race runners are tired but still try to increase their pace as they approach the finish line, thus the number of collapses increase.

• The last 500 m should have several medical staff deployed along the course to act as spotters for runners in distress.

• This is particularly important for mass road races. Equipment and supplies for obtaining vital signs, performing BLSD and ACLS should be available at the finish line.

• The finish line is usually where most medical encounters occur.

• This is the location where the majority of medical staff and volunteers should be.

• The finish line team should include:

  • A Triage Officer and team to direct the flow of casualties to the proper area for care; and

  • Sweep team/field medical personnel divided into medical care teams that can spot runners as soon as they show signs of distress, transporting them to the closest medical point or manage medical illnesses or injuries on site.

Dedicated medical areas may be organised for participants based on injury or illness. The triage team should direct runners to the proper care centre.

8 Documenting Medical Encounters at Community-Based Sporting Events

General race data and medical encounter data at mass community-based endurance sport events should be collected in a standardised format and this has been covered extensively in a recently published international consensus statement [1]. Research methods related to event data collection, athlete demographics, sport code, sport participation history, medical incident data collection procedures and reporting of the data are critical for quality of any scientific studies in this field. The following categories of general race data should be collected (Table 29.7):

• race day data,

• athlete demographics,

• athlete race performance, and

• geographical data of the course.

Table 29.7 Data collection (essential and additional data) on race day, athlete demographics, athlete race performance, course geography, and environmental conditions on race day. (Reproduced with permission from [1])

Medical encounters at mass community-based endurance sports events can be broadly classified into two main diagnostic categories:

• 1. illness-related and

• 2. injury-related medical encounters.

Illness-related medical encounters are usually classified by major organ system affected, while injury-related encounters are usually classified by major anatomical regions affected.

8.1 Illness-Related Medical Encounters

• The use of a diagnostic classification system of illness-related medical encounters by main organ system is recommended (Table 29.8).

• The severity of illness-related medical encounters can further be classified as minor, moderate, serious/life-threatening, and sudden cardiac arrest/death using the definitions described above.

• Additional information can also be collected including the following:

  • the location of the illness on the course (e.g. related to hills, course conditions),

  • pre-race medical history (e.g. pre-race acute illness, use of medications prior or during the event), and

  • other factors possibly contributing to the illness (e.g. weather conditions, equipment failure, athlete inexperience)

Table 29.8 Diagnostic categories of illness-related medical encounters by main organ system and more common specific types/diagnosis of medical encounters. (Reproduced with permission from [1])

8.2 Injury-Related Medical Encounters

• The use of an injury-related medical encounter classification by the main anatomical region affected by the injury, is recommended (Table 29.9).

• The severity of injury-related medical encounters can further be classified as minor, moderate, serious/life-threatening, or death using the definitions described above.

• For injury-related medical encounters, additional information related to

  • the location of the injury on the course (e.g. related to hills, course conditions),

  • onset of the injury (acute injury, chronic injury, acute exacerbation of a chronic injury),

  • mechanism of the injury (e.g. traumatic, non-traumatic, contact or non-contact, nature of the contact), and

  • other factors contributing to the injury (e.g. violation of rules, weather conditions, equipment failure, athlete inexperience)

Table 29.9 Diagnostic categories of injury-related medical encounters by main anatomical region and more common injury types/diagnosis. (Reproduced with permission from [1])

could also be collected.

The adoption of a uniform data collection procedure at the event medical facilities to record all medical encounters is recommended. Recently, a standardised Race Medical Encounter Data (R-MED) form for illness-related medical encounters (Table 29.10) and injury-related medical encounters (Table 29.11) was suggested [1].

Table 29.10 Illness-related Race Medical Encounter Data (R-MED) form—endurance sport events. (Reproduced with permission from [1])

Table 29.11 Injury-related Race Medical Encounter Data (R-MED) form—endurance sport events. (Reproduced with permission from [1])

Clinical Pearls

• The health benefits of regular moderate- to high-intensity physical activity are undisputed, but during such activity there is an increased risk of medical encounters.

• Mass community-based sports events are increasing in popularity, with greater participation among older athletes—this may increase the risk of medical encounters at these events.

• Medical encounters at mass community-based sports events can vary in severity, from sudden cardiac arrest or death, to minor medical encounters.

• Planning to reduce the risk of medical encounters is the responsibility of the race medical director and requires a step-wise approach.

• Pre-race medical screening and educational intervention may reduce the risk of medical encounters.

• The potential negative effects of environmental stress, including air quality, on athlete health can be reduced by careful pre-race planning.

Review

1.1 Questions

• 1. You are appointed as the chief race medical director for a large half-marathon (21.1 km) running event, where the expected number of race starters are about 45,000. The race will be held in a European city in May, and the city is at sea level. Based on current scientific data, which of the following statements are true for the type and severity of medical encounters that you may expect at this race?

  • (a) I can expect that there will be 1–2 runners with sudden cardiac arrest during the race

  • (b) About 5–10 runners will develop serious life-threatening medical encounters

  • (c) I need to plan that there about 2000 runners will require medical attention

  • (d) If the race is held at 2 pm in the afternoon rather than early in morning, it is likely that there will be fewer medical encounters

• 2. In your preparations for the race above (in question 1), where you are the chief medical director responsible for the medical care, which of the following are important considerations at the finish line area?

  • (a) I need to deploy more medical resources and more staff at the finish line than along the course

  • (b) At the finish line area, there should be a dedicated Triage Officer and team to direct the flow of casualties to the proper area for care

  • (c) Equipment and supplies for obtaining vital signs, performing BLSD and ACLS should be available at the finish line.

  • (d) There should be a high-care medical facility at the finish line

• 3. A 56-year-old female runner enters for a marathon for the first time. In preparation for the race she trained for about 10 weeks, with a weekly training distance that averages at 25 km per week. She is a type 2 diabetic, takes anti-depressant medication and has a chronic left rotator cuff impingement in the shoulder for which she uses occasional NSAIDs. What risk factors does this runner have of developing a medical complication during the race? What advice would you give her?

1.2 Answers

• 1. Question

  • (a) Yes: The incidence of sudden death is about 1 in 100,000 entrants, but sudden cardiac arrest is 2–3 higher i.e. 1 in 30,000 to 1 in 50,000

  • (b) No. The incidence of serious life-threatening medical encounters varies but is about 1 in 2000 race starters. Therefore, for a race with about 50,000 starters, you can expect about 25 serious life-threatening medical encounters

  • (c) Yes. The incidence of moderate medical encounters (requiring medical attention) is about 1 in 50. You can expect about 1000 runners that will require medical attention

  • (d) No. If the race is held at 2 pm in the afternoon, it is likely that the environmental conditions will be less favourable in May (spring to early summer in Europe). It is likely that the WBGT will be higher, and if it is above 18°, the risk of medical encounters increases (moderate risk). Higher WBGT will increase the risk even more.

• 2. Question

  • (a) Yes. The number of medical encounters in the final quarter of the race is significantly higher in respect to other segments. Therefore, in the last 2 km of the course, medical staff and supplies should be increased.

  • (b) Yes. A Triage Officer at the finish line area is very important to direct runners with medical complications to the appropriate treatment area—this should be a senior medical doctor with previous race medical care experience.

  • (c) Yes. Equipment and supplies for obtaining vital signs, performing BLSD and ACLS should be available at the finish line.

  • (d) Yes. There should be a high-care medical facility at the finish line.

• 3. Question

  This runner has a number of factors that increase her risk of an acute medical complication during the marathon. She is over 55 years, and is a diabetic and therefore, according to international guidelines, has ≥2 risk factors. The advice would be that she requires a full medical assessment before participating in moderate- to high intensity exercise. It is also important to determine if she has concomitant cardiovascular disease and other complications associated with diabetes. She also uses medications that may increase her risk of a medical complications during exercise, including anti-depressants and NSAIDs. Finally, her training and preparation for a marathon is not optimal because she only started 10 weeks before the marathon, and her weekly training of 25 km is less that what is advised to prepare for a marathon.