Chapter 103 Wilderness and Endurance Events
Perhaps the earliest record of an endurance event may be traced back to ancient Greece in the 5th century BC. The Persians invaded Greece in 490 BC, landing in Marathon, a small town about 26 miles from Athens. Seriously outnumbered by the Persians, the Athenians sent messengers to cities throughout Greece requesting assistance. Legend has it that after the battle, a man named Pheidippides was sent from Marathon to Athens to bring word of the Greek victory. He covered the 26-plus miles on foot, only to drop dead after proclaiming “Niki!” (Victory). Debate continues among historians about what really occurred. For instance, there is evidence that Pheidippides was actually sent from Marathon to request help and that news of the victory was delivered by a man named Eukles.16 Although the exact details remain unclear, when the modern-day Olympic games were inaugurated in Greece in 1896, the legend of Pheidippides served as inspiration for the marathon. That first marathon covered a distance of 40 km (24.85 miles), the distance from Marathon Bridge to Olympic Stadium.47
During the next 28 years, the marathon continued to evolve. In the United States, the Boston Athletic Association held its first marathon on April 19, 1897, to commemorate the famous ride of Paul Revere on that date in 1775. For the Olympic Games in London in 1908, the marathon distance was changed to 26 miles, the distance from Windsor Castle to White City Stadium, with an additional 385 yards added so that the race would finish in front of the royal family’s viewing box. Finally, in the 1924 Olympic Games in Paris, the distance was set at 26.2 miles, establishing the modern-day marathon distance.47 Today, there are hundreds of marathons held throughout the world each year.
Types of Events
Adventure Races
Adventure racing, as we know it today, began in the early 1980s with the first large, well-organized events, including the Coast-to-Coast, started in New Zealand in 1980, and the Alaska Wilderness Classic, started in 1983. These were followed by other well-known events, including New Zealand’s Raid Gauloises and the Southern Traverse, begun in 1989 and 1991, respectively. The Eco-Challenge introduced adventure racing to the United States in 1995. The Primal Quest, started in 2002 in Telluride, Colorado, brought adventure racing more into the mainstream of American sports through network television coverage. In addition to these expedition-length races, there are countless shorter races throughout the world. In the United States, the U.S. Adventure Race Association (USARA) serves as the governing body for adventure racing (http://www.usara.com).
Cycling
USA Cycling, the governing body for mountain biking in the United States, sanctioned more than 50 mountain bike events in 2010 (http://www.usacycling.org); however, this represents only a small fraction of the events held annually.
Marathons
Marathons are perhaps the most popular endurance events. Standard marathons cover 26.2 miles (42 km), whereas ultra-marathons may be 100 miles (160 km) or more. In 2008, there were an estimated 445 marathons held in the United States, with approximately 425,000 finishers (http://www.runningusa.org). In 2010, there were 80 ultra-marathons scheduled in North America, with an estimated 3790 finishers through July 2010 (http://www.run100s.com).
USA Track and Field (USATF; http://www.usatf.org) is the national governing body of long-distance running and is a member of the International Association of Athletics Federations (IAAF; http://www.iffa.org), which sets the rules of competition for all officially sanctioned long-distance running events in the United States and throughout the world. However, the vast majority of marathons in the United States are non-USATF events. Only 73 of the 445 marathons held in the United States in 2008 were certified by the USATF (http://www.runningusa.org/node/16585).
USATF rules of competition allow for sanctioned medical assistance for participants by authorized official event personnel. Current rules do not stipulate specific penalties or disqualification for acceptance of medical assistance, as long as it does not alter the scheduled time of competition for any athlete, interfere with other athletes in the competition, or incorporate the use of illegal or banned substances, technology, or devices that may give the athlete an unfair competitive advantage. A medical official may choose to remove an athlete from competition if the official feels it is medically necessary for the safety of the athlete or for the safety of other athletes in the competition. The use of intravenous fluids or other medications during competition (as long as they are not banned substances) are not specifically listed as grounds for disqualification, but they may be subject to review. Additional rules about clothing, shoes, and athlete interactions with race officials, if breached, may result in disqualification (http://www.usatf.org/about/rules/2010/2010rules.pdf).
Triathlons
Triathlons, which consist of swimming, cycling, and running, are held in various lengths: sprint length (a 400- to 800-m [0.25-mile to 0.5-mile] swim, a 16- to 24-km [10- to 15-mile] bike, and a 5-km [3.1-mile] run); international or Olympic length (1500-m [0.9-mile] swim, 38- to 43-km [24- to 27-mile] bike, 10-km [6-mile] run); and “Ironman” or ultra-triathlon (4-km [2.4-mile] swim, 180-km [112-mile] bike, 34-km [26.2-mile] run) that may last many hours, or days in the case of staged races. USA Triathlon (USAT) is the governing body for triathlons in the United States (http://www.usatriathlon.org).
Most races allow for medical assistance by official event personnel, although rules among events vary and often intentionally leave room for individual interpretation. For example, the rules for the 2010 Ironman Triathlon did not specifically state whether IV fluid administration would be considered grounds for disqualification (http://www.ironmanusa.com/usat-wtc-faq.pdf). Although many unsanctioned events use USAT rules as guidelines, medical providers and participants must be sure to understand the rules of the specific race in which they are involved. It is often helpful to have medical providers participate in development of these rules.
Medical Support for Wilderness and Endurance Events
Mass Gatherings
Information from the study of mass gatherings serves as a background for provision of medical support for wilderness and endurance events. A significant amount of variation exists in the literature concerning the definition of a mass gathering. In some cases, it has been defined as an event with more than 1000 participants; in others, an event is not considered a mass gathering unless there are more than 25,000 participants.7,30
Provision of medical support for any event begins with development of a medical support plan. Several authors have described this process for mass gatherings.8,23,26 The basic goals are to provide rapid access and triage, stabilization and transport of seriously injured or ill patients, and on-site care for minor injuries and illnesses.7 Nine important elements of planning are attendance or crowd size, personnel, medical triage and facilities, communication, transportation, medical records, public information and education, mutual aid, and data collection.23
General recommendations have been made about location and staffing of on-site medical facilities at mass gatherings. One group of investigators recommends that advanced life support (ALS) units be in place so that the response time from collapse to ALS care is 5 minutes or less for all participants under all conditions.41 Others have suggested the goals of basic first aid in 4 minutes, ALS care in 8 minutes, and evacuation to a medical facility within 30 minutes.38 For staffing, it has been suggested that the minimum staffing for every 10,000 participants be a two-person team consisting of registered nurses, emergency medical technicians, or paramedics or a combination of these.
In terms of on-site medical care provision, events may be divided into four categories, classes, or types. Category I events are those in which spectators remain seated for a set period of time or for the duration of the event. Common examples include stadium sporting events and concerts. In category II events, such as golf tournaments, Mardi Gras/Carnival celebrations, and state fairs, spectators are mobile and may become participants in the events. A large geographic area and participants often outnumbering spectators characterize category III events, which include charity walks, bicycle rides, marathons, and triathlons.33 In addition, because of the extreme nature and the unique challenges in providing medical support for adventure races and similar endurance events, several authors have labeled these events as category IV events.5,48,49,51 In general, categories III and IV events do not meet the participant number criterion of mass gatherings.
Most of the existing investigations of medical support involve categories I and II events, with a smaller number of investigations of category III and category IV events. Generally, investigations of categories I and II events have included frequency and type of injuries and illnesses treated, rate of utilization of on-site medical services, and rate of transfer to local care facilities. Their focus has been to determine what factors influence the type and frequency of injuries and illnesses with a goal of better anticipating needs and thus establishing appropriate guidelines and standards of care. Much of the information in these investigations is anecdotal and descriptive; several studies have concluded that there is no standard of care for emergency medical services at mass gatherings.2,7,38,41
The incidence of true medical emergencies at mass gatherings appears to be relatively small. In one large study, 75% of medical encounters involved respiratory illnesses, heat-related injuries, and minor problems, such as sunburn, blisters, and headache. Asthma was the most common reason for required acute medical intervention.3
The relationship between attendance (crowd size) and utilization of on-site medical services is unclear. Several studies have found that overall utilization grew with attendance but that utilization rate did not increase and, in some cases, actually decreased, with larger attendance.2,8,54 Rate of utilization of on-site medical services varies widely among events, ranging from 0.14 to 90 patients per 1000 participants, with most events reporting 0.5 to 2 patients per 1000 participants.2,7,41
Crowd (participant) demographics, event type, and availability of alcohol and drugs may also be used to help estimate utilization of medical resources. As one might predict, studies demonstrate that when alcohol is readily available, there is an increase in medical problems related to intoxication.2,30 One might expect to treat medical problems related to drug and alcohol use during a rock concert. In contrast, during a Papal visit, one might expect less intoxication but more cardiac-related problems.26
In the end, a number of factors may influence the utilization rate and type of medical care required, including the type and duration of the event, weather, availability of alcohol and drugs, and demographics of the crowd, including average age, density, and mood.2,3,30
Wilderness And Endurance Events
Wilderness and endurance events often occur in rough and remote terrain where communication may be very difficult, transport time to definitive care prolonged, and technical search and rescue required. In some wilderness events, the entire course is set, whereas in others, there is no set course between checkpoints and transition areas. In events with no set course, the exact location of each team may be unknown. In addition, many of these events are not staged, resulting in hundreds of miles separating lead teams from the back of the pack (Figure 103-1). Categories III and IV events present additional challenges in the provision of medical care and represent a new and important area of event and wilderness medicine.
Development of a Medical Support Plan
Provision of medical support for any event begins with development of a medical support plan. The importance of early planning, organization, and good communication cannot be overemphasized.52 For any event, the medical support plan should be based on anticipation of need. This begins with estimation of both number of patients and type of injuries and illnesses that will require treatment in both the best-case and worst-case scenarios. It is often helpful to review utilization of medical resources for similar events that have been held.26 In addition, as previously described, a number of factors that influence utilization of medical resources should be considered.
Development of a medical support plan should be done under direction of the event’s medical director. The primary responsibilities of the medical director are the health and safety of participants. The medical director may be a physician, paramedic, emergency medical technician, nurse, or other medical professional. Ideally, this individual should have prior experience as a medical director for similar events and will serve as care provider, planner, advisor, educator, and liaison with the community.19 It is essential that the director be familiar with the location of the event, including the capability of local emergency medical services (EMS), local health care facilities, and in the case of category IV events such as adventure races, local search and rescue (SAR) system. Medical support plan development should begin several months to several years before the event, depending on event complexity.
Development of a medical support plan begins with careful review of the course, including its location, disciplines required, time of year, and the climate conditions, including precipitation, temperature, and humidity. In this way, the occurrence and type of injuries, illnesses, endemic diseases, and environmental emergencies, such as dehydration, heat and cold illness, and altitude illness, can be roughly anticipated. High temperature and relative humidity can have a major effect on utilization of on-site medical resources. Both of these factors are associated with increases in demand for on-site medical services; however, humidity has a larger effect than does temperature. In mass gatherings, availability of water also influenced the incidences of dehydration and heat illness.2,7,26 For any event, it is important to know the likely temperature and humidity and to plan accordingly.
In general, the medical support plan should be comprehensive and outline all aspects of medical support, including a complete list of medical supplies, equipment, and personnel (Box 103-1). Treatment and transfer protocols should be clearly outlined, assigning any penalties for receiving medical care and establishing indications for medical disqualification or withdrawal from the event. It is important that the medical support plan be based on estimates of the type and frequency of injuries and illnesses expected in both the best and worst case scenarios.
