The needs of the athletes competing must be considered prior to the event.

Specific considerations of the type of event, number of participants, course peculiarities, and environmental predictions are all very important in determining the medical coverage required.

The formation and implementation of an emergency action plan have proven successful in numerous situations (5).

As a key advisor to the event director, the medical director must ensure that the event is conducted with the safety of the competitors being of utmost importance. Often, this is furthest from the minds of race organizers especially with competing priorities of sponsor, financial, and community concerns.

In extreme conditions, the race may need to be cancelled or rescheduled (17). It is best that these possibilities and contingency plans be discussed and prepared prior to the race day.

It is often necessary to review the course for any potential trouble spots and hazards that could cause injury. The start and finish are common sites of medical concern. The start area should be on a large level surface devoid of obstacles, thereby allowing the athletes to more easily accommodate the surge that invariably occurs. The finish area should also be large enough to prevent the athletes from bunching up and being forced to stand in one place. It should also have necessary facilities and resources to allow the athletes to properly cool down and recover after the event and easily access medical treatment areas as required.

Biking, swimming, and skiing events carry additional risk elements (8,15,22), such as water safety and trauma potential associated with high speeds. Water temperature; sea conditions; road conditions; transition, acceleration, and deceleration zones; and protective equipment must be carefully scrutinized.

Running (42 km), 1%-20%; running (< 21 km), 1%-5%; triathlon (225 km), 15%-30%; Nordic skiing (55 km), 5%; triathlon (51 km), 2%-5%; cycling (variable), 5% (20).

Injury rate increases with increased distance and environmental temperature (9,10).

Previous years’ experience is very helpful in planning for subsequent years. This also stresses the importance of a reliable injury data tracking system.

Similar events in similar elements can be used in the initial planning and preparation stages.

Fortunately, the risk for exertional death in marathons is quite small (13).

The level of medical care that will be available on the course must be defined and agreed on between the medical director and the event director early in the planning stage.

This may differ among the aid stations throughout the course with the most robust resources usually being provided at the finish area.

It is essential to provide on-site basic first aid and cardiopulmonary resuscitation (CPR). It is desirable to provide on-site early defibrillation, advanced cardiac life support (ACLS), and advanced trauma life support (ATLS).

The usage and type of intravenous fluids and availability of oxygen, medications, and advanced cardiac and trauma life support equipment are all areas requiring discussion.

Coordination with the local emergency medical system (EMS) and emergency rooms and hospitals is absolutely required.

Mobile medical assets in the form of bike or canoe/kayak teams or EMS units provide an excellent means to access injured competitors throughout the course (12,14).

A decision must be made as to the provision of medication on the race course and in the medical aid stations. It is recommended that these medications be tightly controlled and kept to a minimum if dispensed at all.

In longer events, it is not uncommon for athletes to carry and take their own medication during the competition. This must be anticipated to best treat the competitor and prevent overprescribing.

The availability of urgent or emergency medication, such as aspirin, epinephrine autoinjector, albuterol metered-dose inhaler, glucose, and ACLS medications, should be considered.

Medical aid stations may or may not have basic laboratory capability. The ability to assess an athletes’blood glucose and sodium levels will assist with their rapid evaluation and allow for the appropriate treatment of a collapsed athlete (6,11).

Hand-held glucose and electrolyte monitors are readily available and have become part of the standard medical kit for many endurance events (21).