Medical Coverage Plans for Medical Coverage Plans for Large Scale Athletic EventsLarge Scale Athletic Events

Chris Troyanos, ATCChris Troyanos, ATCSports Medicine Sports Medicine ConsultantsConsultants, Inc, Inc

troyanos@babson.edutroyanos@babson.edu

Medical Role in Race OperationsMedical Role in Race Operations

•• Ensure event safetyEnsure event safety•• Provide medical careProvide medical care•• Medical decisionsMedical decisions•• Act as Medical Act as Medical

SpokespersonSpokesperson•• Coordination of city, Coordination of city,

town, state agenciestown, state agencies

Race Medical Operations Race Medical Operations PurposePurpose

•• PrePre--racerace-- Improve athleteImprove athlete’’s safetys safety-- Prevent excessive injury or illnessPrevent excessive injury or illness-- Head off legal issuesHead off legal issues-- Coordination with Race StaffCoordination with Race Staff-- Coordination with City, State, Local agenciesCoordination with City, State, Local agencies

Race Medical Operations Race Medical Operations PurposePurpose

•• Race Day (primary focus)Race Day (primary focus)-- Stop progression of injury or illnessStop progression of injury or illness

(triage, treatment, transfer)(triage, treatment, transfer)-- Do no harmDo no harm-- Rapid response to all locationsRapid response to all locations-- Stay within training levelsStay within training levels-- Prevent emergency room overloadPrevent emergency room overload

Race Medical OperationsRace Medical Operations

•• PostPost--RaceRace-- Injury/Illness follow up Injury/Illness follow up -- Evaluation of medical planEvaluation of medical plan-- Medical volunteer retentionMedical volunteer retention-- Improve each yearImprove each year-- DonDon’’t be afraid to lead the packt be afraid to lead the pack

Medical Coverage/Planned Medical Coverage/Planned DisasterDisaster

•• Mass GatheringMass Gathering-- Potential for Potential for CasualtiesCasualties-- Staff and spectator Staff and spectator concernsconcerns-- Medical control during Medical control during mass casualty planmass casualty plan

Medical ConcernsMedical Concerns

•• DehydrationDehydration•• Cardiac EventsCardiac Events•• Hyper/HypothermiaHyper/Hypothermia•• HyponatremiaHyponatremia•• Podiatatric issuesPodiatatric issues•• Overuse InjuriesOveruse Injuries•• OthersOthers

Collapse Before/After Finish LineCollapse Before/After Finish LineEssential organ systems not functioning ~ BADEssential organ systems not functioning ~ BAD

BeforeBeforeCardiac ArrestCardiac ArrestHeat StokeHeat StokeHyponatremiaHyponatremiaRhabdomyolysisRhabdomyolysisInsulin ShockInsulin ShockAnaphylaxis

AfterAfterDehydrationDehydrationPostural HypotensionPostural HypotensionExercise Associated Exercise Associated

Collapse (EAC)Collapse (EAC)““Just happy to be thereJust happy to be there””

Anaphylaxis

Medical PreparationMedical Preparation•• Competitor SafetyCompetitor Safety•• Preparticipation Preparticipation

ScreeningScreening•• Hazardous ConditionsHazardous Conditions•• Competitor EducationCompetitor Education•• Impaired competitor Impaired competitor

policypolicy•• Race schedulingRace scheduling•• ER notificationER notification•• Communications

•• Fluid ProtocolsFluid Protocols•• Equipment/SuppliesEquipment/Supplies•• Medical StaffingMedical Staffing•• Medical RecordsMedical Records•• Medical ProtocolsMedical Protocols•• SD ProtocolSD Protocol•• HIPPA/federal HIPPA/federal

regulationsregulations•• Transportation PlansTransportation Plans

Communications

Competitor EducationCompetitor Education•• Safety MeasuresSafety Measures•• Risks of participationRisks of participation•• Fitness RequirementsFitness Requirements•• Hydration RisksHydration Risks•• NutritionNutrition•• Finishing StrategiesFinishing Strategies•• Volunteer Volunteer

IdentificationIdentification•• Medical LocationsMedical Locations

Race Bib/Medical InformationRace Bib/Medical Information

•• Back side of bibBack side of bib-- Name, age, DOBName, age, DOB-- Emergency contact with phone numberEmergency contact with phone number-- Known medical problemsKnown medical problems-- Medications, supplements, dosageMedications, supplements, dosage-- Physical limitationsPhysical limitations-- AllergiesAllergies

Incidence/Risk of InjuryIncidence/Risk of Injury

•• Boston Marathon (normal year) 3Boston Marathon (normal year) 3--6%6%•• Boston Marathon 2004 10%Boston Marathon 2004 10%•• Twin Cities Marathon Twin Cities Marathon .8 to 3.3%.8 to 3.3%•• Houston MarathonHouston Marathon 6%6%•• Pittsburgh MarathonPittsburgh Marathon 10%10%•• Falmouth Road RaceFalmouth Road Race 1%1%•• Iron Man Tri (225km) Iron Man Tri (225km) 1515--35%35%

PeoplePeople’’s Beach to Beacon s Beach to Beacon Injury RateInjury Rate

Based on 5000 runnersBased on 5000 runners

•• 1998 1998 4545•• 19991999 3333•• 20002000 6060•• 20012001 5656•• 20022002 5252•• 20032003 2929

Risk FactorsRisk Factors

•• WeatherWeather•• Fitness levels of Fitness levels of

participantsparticipants•• Course Course

layout/difficultylayout/difficulty•• Participants Medical Participants Medical

HistoryHistory•• The UnknownThe Unknown

Heat InjuriesHeat Injuries

•• Heat CrampsHeat Cramps•• Heat SyncopeHeat Syncope•• Heat ExhaustionHeat Exhaustion•• Heat StrokeHeat Stroke

Heat Stroke Heat Stroke ““true sports emergencytrue sports emergency’’

•• Body Core Temperature Body Core Temperature > 40.5 C/104 F> 40.5 C/104 F

•• Exertional Heat Stroke = Exertional Heat Stroke = SweatingSweating

•• Mental Status ChangesMental Status Changes•• Can occur even in moderate Can occur even in moderate

conditionsconditions•• FactorsFactors……. Air . Air

Temp/humidity/solar Temp/humidity/solar radiation/metabolism/clothingradiation/metabolism/clothing

•• Body cannot dissipate heatBody cannot dissipate heat•• Other medical factorsOther medical factors

Emergency CareEmergency Care

•• Cooling body core TemperatureCooling body core Temperature•• Ice bath (full body immersion)Ice bath (full body immersion)•• Ice application to neck/axilla/groinIce application to neck/axilla/groin•• Fluids (water/sports drinks)Fluids (water/sports drinks)•• IVIV’’s (normal saline)s (normal saline)•• Extremity elevationExtremity elevation•• Differential Diagnosis Differential Diagnosis -- HyponatremiaHyponatremia

Blood ChemistriesBlood ChemistriesWhat happens to a runnerWhat happens to a runner’’s bloods blood

•• BUNBUN•• Calcium (Ca)Calcium (Ca)•• Sodium (Na)Sodium (Na)•• GlucoseGlucose•• HematocritHematocrit•• MagnesiumMagnesium•• Total ProteinTotal Protein

Hypothermia Hypothermia ““the cold runnerthe cold runner””

•• Body Core Body Core Temperature of < 90 Temperature of < 90 DegreeDegree’’ss

•• Depressed Vital SignsDepressed Vital Signs•• Altered Level of Altered Level of

Consciousness Consciousness •• ShiveringShivering•• DehydratedDehydrated•• HypovolemicHypovolemic

Hypothermia TreatmentsHypothermia Treatments

•• Establish VitalsEstablish Vitals•• Remove Wet ClothesRemove Wet Clothes•• Warm PatientWarm Patient•• Drink Warm FluidsDrink Warm Fluids•• IV Therapy (warmed IV Therapy (warmed

to 104to 104--106 degrees)106 degrees)•• O2 O2 •• Bair Hugger Bair Hugger

HyponatremiaHyponatremia

Clinical ProfileClinical Profile-- Slow runner > 4 hoursSlow runner > 4 hours-- Small statureSmall stature-- Female genderFemale gender-- Over hydratedOver hydrated-- > on a hot day> on a hot day-- > with use of NSAIDS> with use of NSAIDS* Cause of death in 2002

SymptomsSymptoms-- Light headedLight headed-- Nausea/vomitingNausea/vomiting-- ConfusionConfusion-- Salty sweaterSalty sweater-- EdematousEdematous-- Normal vitalsNormal vitals-- Weight gainWeight gain

* Cause of death in 2002

Symptoms of Symptoms of HyponatremiaHyponatremia

•• Mild (sodium 131Mild (sodium 131--135mm): usually 135mm): usually asymptomaticasymptomatic

•• Moderate (Na 126Moderate (Na 126--130):Malaise, nausea, 130):Malaise, nausea, fatigue, confusionfatigue, confusion

•• Severe (Na < ): coma, seizures, deathSevere (Na < ): coma, seizures, death

•• ?? Use of hot saline in severe cases?? Use of hot saline in severe cases

Avoiding Avoiding HyponatremiaHyponatremia•• Determine sweat rate/fluid replacement.Determine sweat rate/fluid replacement.•• 1 pint replaces 1 pound of water weight.1 pint replaces 1 pound of water weight.•• Have runner write weight on race bib.Have runner write weight on race bib.•• Do not overload on fluids!!Do not overload on fluids!!•• Eat Eat ““saltysalty”” snacks or drink bouillon post race.snacks or drink bouillon post race.•• Do not continue to drink fluids post race if you Do not continue to drink fluids post race if you

are feeling sick.are feeling sick.•• Only return to normal drinking post race until Only return to normal drinking post race until

after you have started to urinate.after you have started to urinate.•• Avoid NSAIDS.Avoid NSAIDS.

HyponatremiaHyponatremiaManagement GuidelinesManagement Guidelines

•• CourseCourseSymptomatic w/profileSymptomatic w/profile-- No oral/IV fluidsNo oral/IV fluids-- Immediate ED transportImmediate ED transport

Mild or asymptomaticMild or asymptomatic-- Monitor with no fluids until Monitor with no fluids until

able to urinateable to urinate-- Gatorade only/salty foodsGatorade only/salty foods-- Advise fluid intake of 8oz per Advise fluid intake of 8oz per

hour for the next 24 hours

•• Medical TentMedical TentSerum sodium < 125 MMols/LSerum sodium < 125 MMols/L-- Start IV line/ keep open with Start IV line/ keep open with

normal saline normal saline -- Immediate transportImmediate transport

Serum sodium 125Serum sodium 125--130 MMols/L130 MMols/L-- No more that 8oz. Of fluids until No more that 8oz. Of fluids until

spontaneous urinationspontaneous urination-- Observe for no more than 30 min.Observe for no more than 30 min.-- Discharge with instruction sheetDischarge with instruction sheet

Serum sodium > 130 MMols/LSerum sodium > 130 MMols/L-- Advise runner not to drink more Advise runner not to drink more

than 8 0z. Of fluids until they than 8 0z. Of fluids until they begin to urinate

hour for the next 24 hours

begin to urinate

Risk of Sudden Death Risk of Sudden Death in Road Racingin Road Racing

* * CardiacCardiac-- Estimated 1/100,000 Estimated 1/100,000

entrantsentrants-- Increased age of runnersIncreased age of runners-- Over 40 = CADOver 40 = CAD-- Under 30 = Cardiac Under 30 = Cardiac

AnomalyAnomaly* Hyponatremia* Hyponatremia-- Low frequencyLow frequency-- Slow runnersSlow runners