Mass Participation Events

Helen D. Iams MD, MS

James Williams MD

Key Points

Events with more than 1,000 participants are classified as mass participation events.
The medical care system at a sports event will need to manage a high volume of minor issues, while remaining prepared to quickly identify and treat life-threatening problems.
High-speed events have the potential for life-threatening trauma and require preparation for the management of such injuries.
Design of the medical system should begin months in advance and be based on the length and intensity of the event and the risk of catastrophic injury.
Physicians can help administrators plan a safer event. In hot climates, start times should be scheduled for early in the day or in the evening. In cold climates, events should start mid-day.
Identifying the risk of injury in hot weather is best done using a wet bulb globe thermometer.
Consideration needs to be given to where injuries are most likely to happen. Possible evacuation routes and traffic and pedestrian control need to be planned accordingly.
Costs can be minimized by borrowing supplies. Among the possible sources are the National Guard, American Red Cross, Coast Guard, and the National Ski Patrol.
The entire medical staff should have distinctive clothing or hats so that it can be easily identified by other race workers and athletes.
One physician needs to serve as medical director and is often so busy that he or she can not provide medical care. The medical director organizes and supervises the medical operations and serves as spokesperson in the case of an adverse event.
The physicians staffing a sports event need to have experience in managing the injuries that may be encountered. This makes orthopaedic surgeons, family physicians, and emergency physicians the most frequently recruited. Podiatrists are helpful at running events.
Ideally, liability is provided by the race administration. Physicians need to carefully review liability coverage before becoming involved.

Endurance sports events are growing in popularity and drawing increasingly large fields of participants. Events with over 1,000 participants, classified as mass participation events, have become common (1). Often, the race administration will ask local physicians to provide medical coverage for these events. Being able to fulfill this role requires that the physician understand the unique aspects of large sports events and how these aspects can affect medical care. Injury rates at mass sports events can be as high as 30%, necessitating a medical system that can handle a high volume of injuries (2). The medical staff may encounter a wide variety of injuries, from minor musculoskeletal pain to life-threatening trauma. The principles for providing medical care for athletes are the same whether the event is an Ironman or the local 5-km charity run. The medical care system at a sports event needs to be able to evaluate and treat injuries on site, to arrest the progression of serious injuries, to stabilize critical patients for transfer, and to minimize the impact of the event on the local emergency medical system (3). This chapter focuses on the special aspects of providing care for athletes. There is usually a separate medical team for spectators. If spectators are to be treated by the same medical staff, the medical staff will need to be larger and have more extensive supplies. Spectators present with a different
spectrum of medical problems and tend to require more intensive care (1,4,5).

Planning

The medical director needs to design the medical care specifically for each sports event. The medical care system will need to manage a high volume of minor problems and yet still be able to quickly identify and treat life-threatening problems (2,5). Fortunately, serious problems, such as cardiac arrest and hyponatremia, are rare (6). The majority of injuries will be mild and self-limiting (7). For example, typical problems among athletes at the 1984 Olympics were minor musculoskeletal injuries, exercise-associated collapse, heat exhaustion, and dermatological complaints (4).

Different types of events will create different challenges for the medical team (8). Large venues, such as marathon courses, make it difficult to get medical personnel to injured athletes (9). Events that last over 4 hours have higher incidences of overhydration and hyponatremia (10). Extreme weather conditions increase the likelihood of injuries, and changing weather can create hazardous conditions in a short period of time. Courses that extend into remote areas tend to have poor access. High-speed events such as cycling, rollerblading, downhill skiing, or wheelchair races have the potential for life-threatening trauma and require the medical staff to be prepared to manage such injuries. Longer races have higher rates of injury but fewer entrants. Shorter races usually need less extensive medical care. However, catastrophic injuries can still happen even in shorter races, and there is a greater risk of heat illness with shorter, more intense events (2). Being prepared for all these tasks takes a significant amount of planning. Design of the medical system should begin months in advance of the competition.

The demographics of the athletes and their fitness levels will affect the injury rates. An event that encourages novices to participate requires special consideration as well. Novices often underestimate the amount of preparation they need, leaving them more prone to injuries and improper hydration (10). Smaller competitors, such as youth and women, are more at risk of developing hyponatremia and dehydration (6,11). Identifying the high-risk aspects of a particular competition will enable a physician to custom design an optimal medical care system.

Safety

Improving the safety of a competition involves more than just caring for injuries. Physicians can help race administration provide a safer event by considering factors such as the predicted weather, start times, and event regulations. Events should not be scheduled in extremely hot months, extremely humid months, or extremely cold months (12). If the date of the event cannot be moved to a safer season, the start time should be moved to a safer time of day (3,7,12,13). In hot climates, start times should be scheduled for early in the day or in the evening. In cold climates, events should start mid-day. Event regulations can also increase athlete safety. For instance, requiring helmets for high-speed events in cycling and wheelchair races can decrease the incidence of serious head injuries (3). Other regulations, such as all medical personnel using universal precautions, can protect the volunteers as well as the athletes (12).

Course conditions need to be monitored during the event. The course may develop hazards such as dangerous water conditions in open water swims and poor traction in high-speed events. Changing environmental conditions can quickly create hazardous conditions for the athletes and volunteers (3). Temperature, humidity, and wind chill need to be monitored on site during the event because measurements made at a remote weather station may not reflect the conditions at the event (3,7,13,14). In cold weather, the wind chill dictates the risk of injury. The wind chill can be determined from the wind speed and the ambient temperature (12). Wind speeds can be estimated from observing the effect of the wind on nearby trees. If you can feel the wind on your face but trees are not moving, the wind speed is about 10 mph. If the small branches are moving, the wind speed is about 20 mph. Larger branches move at 30 mph, and entire trees will move in 40-mph winds (15). At 10°F and below, there is an increased chance of injury when the wind speed is 20 mph or greater. At -10°F, the likelihood of injury increases at wind speeds of 10 mph. There is a high likelihood of injury if the temperature is -20°F and the wind speed is over 30 mph (15).

Identifying the risk of injury in hot weather is best done using a wet bulb globe thermometer (WGBT) (12,13). WGBT readings take into account the combined effects of heat and humidity and thus are better indicators of environmental hazards than temperature alone (Table 60-1). If a WGBT is not available, the risk of heat injury can be estimated using the local temperature and humidity readings and data published by the National Weather Service (Table 60-2) (16). If the risk of injury is high and the event cannot be rescheduled, the event can be modified to decrease the chance of heat injuries. For timed games, half-time can be increased, play times can be shortened, and more water breaks can be allowed (13,17). The game’s regulations can be modified to allow unlimited substitutions during play (13). Arrangements can also be made to spray water on the athletes (13). As the risk of heat injury rises, more of these modifications should be used at the same time.

A cancellation policy for stopping or rescheduling the event should be developed and published in advance. Warm weather conditions posing high environmental risk for hyperthermia have been summarized by the American College of Sports Medicine (ACSM) (Table 60-1). Cross-country ski races should be canceled if the ambient temperature is below -4°F, even if there is no wind. This is because
the wind chill generated by skiers moving at race speed creates a very high risk of cold injury (12). There should be a designated weather watcher to evaluate conditions as the day progresses. If hazardous conditions develop, the weather watcher must have the authority to stop the event.

Youth are at greater risk for heat collapse than adults. Youth do not tolerate the heat as well due to the fact that they do not sweat as much as adults and have less efficient body temperature control regulation. They also have a greater surface area to mass ratio, which causes them to gain proportionally more heat in a hot environment (18). It cannot be assumed that young athletes will understand how to pace themselves during activity in a hot and humid environment. Due to these factors, young athletes may need a modified cancellation policy (18).

A separate plan for lightning hazard must also be developed. The current recommendations are to stop the event for flash-to-bang times under 30 seconds and not to resume activity until 30 minutes after the last sighted lightning (19). Shelter for competitors in case of dangerous weather needs to be identified ahead of time.

TABLE 60-1 Risks of Environmental Injury

Risk of Injury	WBGT	Recommendations
Moderate	<50°F	All participants at risk for hypothermia Very low risk for hyperthermia Windy, wet conditions increase risk of hypothermia
Low	50–65°F	Hyperthermia or hypothermia unlikely to occur
Moderate	65–73°F	Advise heat-sensitive participants to decrease intensity
High	73–82°F	All participants at risk for hyperthermia Advise heat-sensitive participants to withdraw
Extremely high	>82°F	Extreme risk for of hyperthermia for all participants Cancel, reschedule, or modify event if possible
Adapted from Armstrong LE, Epstein Y, Greenleaf JE, et al. American College of Sports Medicine position stand: heat and cold illnesses during distance running. Med Sci Sports Exerc 1996;28:i–x; and Elias SR, Roberts WO, Thorson DC. Team sports in hot weather: guidelines for modifying youth soccer. Phys Sportsmed. 1991;19:67–78.

TABLE 60-2 Estimating Heat Risk

Humidity	Moderate Risk	High Risk	Hazardous
40%	90°F	100°F	110°F
50%	90°F	95°F	105°F
60%	85°F	95°F	105°F
70%	85°F	90°F	100°F
80% and up	85°F	90°F	95°F
National Weather Service. Heat Index. http://www.nws.noaa.gov/om/heat/index.shtml. Accessed October 10, 2006.

Route

The course itself will influence the types of injuries that occur and the ability of medical personnel to reach injured athletes. It needs to be closely inspected by the medical team before the event so that they can anticipate where problems may develop. Consideration needs to be given where injuries are most likely to happen, possible evacuation routes, and traffic and pedestrian control (3,5). Emergency vehicles will need routes to take medical staff to injured athletes and to take injured athletes to the local emergency room (1). Familiarity with the course will allow optimal placement of medical stations and ambulances. First aid stations need to be clearly identified and easily reached by medical staff and athletes. For road races, the main first aid station should be positioned adjacent to the finish line. For longer road races and large tournaments, multiple stations may be needed.

Some unique hazards may require additional attention (3,8). Large bodies of water may require spotters on the water (3). Triathlons need additional coverage in swim and transitions areas (20). Routes that include a downhill section increase the chances of wheelchair and cycling crashes (3). Fixed objects near high-speed courses need to be padded. These include telephone poles, trees, signs, and mail boxes. Cross-country ski courses and mountain bike courses often stretch through remote areas. Plans for getting emergency personnel to remote parts of the course need to be created ahead of time.

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