Appropriate staffing of the on-site medical team is essential for the provision of optimal medical support for expedition-length adventure races. In the majority of events, there is a medical director and medical team members all of whom may be volunteers. Team members should have a collective balance of experience in event medicine, wilderness medicine, emergency medicine, and prehospital care including SAR. Those with experience in previous expedition-length adventure races may be particularly valuable members of the team. Staffing of each medical station should include individuals with appropriate training, experience, and skills in three general areas of expertise: (1) patient assessment, (2) IV placement and fluid and medication administration, and (3) patient packaging for evacuation. These skills may be represented by one individual but more likely multiple individuals will be necessary to include the appropriate scope of skills.

In addition to these three main areas of expertise, additional personnel may be invaluable in particular settings. For instance, foot care including treatment of blisters is a very common chief complaint during expedition-length adventure races especially after long sections requiring foot travel. It is beneficial to have personnel with expertise in foot care stationed at the TA after these sections as there will likely be a large number of participants requiring treatment of foot-related problems [2–4]. This is less likely to be the case after mountain biking or boating sections of the course.

The ideal staffing for a medical station is a medical team with a diverse and complimentary skill set, a team attitude, and an ability to work together in a nontraditional and often demanding context.

One of the biggest challenges in provision of medical support for expedition-length adventure races is predicting both the type and amount of medical equipment and supplies that will be necessary. Each medical station should be supplied with adequate equipment and supplies for the duration of the event. This should be based on anticipation of need in both the best- and worst-case scenarios.

A careful review of the course may help in predicting anticipated need. It is also useful to review previous events. Even with the careful review and knowledge of previous events, anticipation of need may be very challenging as each expedition-length adventure race is different. A previously cited example is the 2002 Primal Quest held in Telluride, Colorado. In pre-race screening, few athletes reported asthma including exercise-induced asthma; however, during the event, there were a large number of participants who requiring beta-agonist inhalers for wheezing, thought to be secondary to a combination of poor air quality from forest fires in the area as well as a viral respiratory illness that spread among the participants [4]. During the same event held a year later in South Lake Tahoe, California, almost no beta-agonist inhalers were administered; however prednisone was in short supply due to many of the participants contacting poison ivy along the course.

A comprehensive list of all the equipment, supplies, and medications should be included in the medical support plan and a copy available at each medical station. In general, all medical stations should be stocked with the same supplies. The amount of supplies may vary from one medical station to the next depending on anticipated need; however the basic supplies should be the same. This standardization of equipment is helpful as medical staff can be informed of what is available and will not look for items that are not stocked. In addition creation of standard kits or carts should allow for familiarity, increased efficiency, and reduced errors. The amount of each supply may vary depending on anticipated need. For example, the stock of foot care supplies should be in greater amounts at the TA after a long section of the course requiring foot travel compared with the TA after a boating section of the course. In addition there may be specialized pieces of equipment where placement is critical. For example, a portable altitude chamber should be placed on the course where it is anticipated that high-altitude illness will occur and descent may not always be possible.

Equipment and supplies should be stored in durable, portable containers. Items should be in the original packaging, placed in clear plastic bags or storage containers labeled with the contents in the appropriate relevant languages.

Expedition-length adventure races utilize different methods of communicating between race staff including medical staff and race participants. Ideally, a primary and secondary system should be utilized, as no communication system is consistently reliable in these environments. Mobile or cellular telephones offer private, relatively low-cost communication but require a network that may not be available in the environments in which these events take place. Satellite phones also offer private communication and over a worldwide network however at significant cost. Radios have the advantages of reliable communication in a wide variety of terrain; however they may require setting up repeaters that require power and do not offer private communication which is a disadvantage for medical communications. It is strongly recommended that two communication systems be utilized such as radios as a primary system and satellite phones as a secondary system.

Given the limitations in communications including inherent unreliability, it is important to utilize a standard system for teams to quickly and accurately relate important information about the situation to the medical and event staff. One system that has been used is a three-tier classification of medical emergencies. Class 1 emergencies are minor, requiring no evacuation, and the participant will proceed with their team and receive evaluation and treatment at the nearest medical station. Examples include a sprained wrist or sunburn. Class 2 emergencies are not life threatening but require evacuation. An example is a tibia-fibula fracture. Class 3 emergencies are potentially life threatening, requiring immediate evacuation. Examples include a head injury or respiratory distress. Utilizing this system, a team can quickly relate the urgency of the situation in the event communication is not consistent.

When an injury or illness occurs along the course that requires evacuation, it is critical to be able to quickly and accurately locate the ill or injured participant. As previously discussed, communication can be unreliable, and even when communication is available, participants may not be able to accurately relate their position.

Global Positioning Systems (GPS) technology has become the standard for tracking participants in large expedition-length adventure races. Compared with alternatives, it provides increased accuracy and capability for locating and tracking participants and greatly enhances the ability of event staff including medical staff to coordinate and execute a rescue and medical response when necessary.

During some expedition-length adventure races, teams may carry a small case containing a GPS tracking unit and a radio or satellite phone. These devices send a signal every hour giving the location of the team to event staff. The device has no display so the team cannot use it to determine their location. In the event of an emergency, the team flips a switch on the device that changes the signal received by event staff to a distress signal, indicating there is a problem. The team then relates the nature of the emergency to race staff utilizing the radio or satellite phone contained in the device. Utilizing this system, race staff quickly learns the nature of the emergency and the exact location of the team.

If such a system is utilized, a secondary system should also be in place, as GPS and communication devices such as radios and satellite phones may not work in these remote and rugged environments. The ideal overall tracking system will require a combination of the multiple modalities. What works best will depend on the location, course, terrain, existing infrastructure, weather, and budget of the particular event.

Appropriate location of medical stations along the course and placement of personnel, supplies, and equipment is essential to ensure effective medical support for the event. In the majority of expedition-length adventure races, the main medical stations are located at TA. There may be great distance between TA, often 25 miles or more, which is significantly longer than in marathons or ultramarathons, that may have spacing of medical stations every 1 mile or 5 miles, respectively. Due to the long distance between TA, medical stations are also placed at strategic locations throughout the course, including certain checkpoints and utilizing mobile medical teams, taking into consideration anticipation of need. Utilizing alternative locations for medical stations such as checkpoints and mobile teams may be very useful to provide adequate coverage for expedition-length adventure races that may have a 400-mile or longer course.

Each medical station should have a binder with critical information specific to that station from the medical support plan. For instance, for each main medical station along the course, most of which will be located at TA, it is important to list all access points in the binder. This should include maps of road access for emergency vehicles coming to the medical station to pick up a patient and transport them to the appropriate facility. In addition, this should include the location of the closest landing zone (LZ) for a helicopter if evacuation by air becomes necessary. In addition, the binder should contain the location of the medical station in language that the local EMS or SAR personnel can understand. This may include a description of the location in the local language and using local terms. For example, instead of identifying a medical station as “Medical Tent #4,” it should also be identified with local landmarks, such as “Ocean Beach Trailhead off County Road 33.”

Each medical station should be stocked with adequate supplies. Certain large or expensive pieces of equipment, such as portable hyperbaric chambers, may need to be moved from one medical station to another during the event. They may need to be leapfrogged from one medical station to another as the race progresses. The movement of critical supplies and equipment should be planned out ahead of the race. Flexibility should be built in, as timing of the event and use of the equipment and supplies may be impossible to accurately predict.

Transportation for both medical teams and evacuation of patients is an important consideration, given both the large geographic area typically covered by an expedition-length adventure race and the rugged variety of terrain. The medical support plan should include the specific plan for evacuation for every portion of the course. This includes listing local SAR and EMS if available as well as the location of the closest facility and comprehensive facility along with their capacities and capabilities. For each point along the course including the medical stations, will local SAR and EMS respond or will the event be responsible for locating and transporting ill or injured participants to a location where care can be transferred to the local medical system? Some parts of the course may be accessible by ALS ambulance; however large sections of the course may be accessible only by 4-wheel-drive vehicle, watercraft, and helicopter. It is preferred to utilize local SAR and EMS including local air medical resources as they are familiar with the area and systems and communication standards and treatment guidelines will already be in place.

Establishing accessibility of the local emergency network such as 911 or similar, at each point along the course, should occur prior to event operations. If such a network is in place, for each position along the course, it is important to know if it can be accessed using cellular/mobile phones or if satellite phones are required. For both out-of-area cellular phones and satellite phones, access should be tested. If such as system is not in place, it is important to know how to contact local SAR and EMS. In each case, protocols for notification and activation of local SAR, EMS, and hospitals should be disseminated to medical personnel and contained in the medical support plan in a binder at all medical stations along the course.

In some events, local EMS and SAR will not have sufficient capacity or capabilities and the event will be responsible for evacuation and transport of patients to local facilities. In these situations, it may be necessary to utilize event resources, such as event vehicles or helicopters normally used for media or event staff transportation, for patient evacuation and transport. The ability to provide these additional services will be very dependent on the pilot’s experience, knowledge of the area, and comfort level. The plan for this alternative use of the helicopter should be well established and agreed upon by all parties prior to the event.

If the event budget will allow, in situations where local SAR or EMS is insufficient, the event staffing should include privately hired staffed advanced life support (ALS) ambulances that are positioned strategically along the course.

A basic objective of the medical support plan for any expedition-length adventure race is to provide definitive care for patients with minor injury and illness and stabilize and facilitate evacuation of patients with severe injury and illness. The specifics about the types of injury and illness that may receive definitive treatment by event medical staff will depend on a number of factors including the location of the event and local access to quality definitive medical care and the qualifications, training, and experience of the medical providers on the event medical staff. This “scope of practice” should be outlined in the medical support plan.

The medical support plan must take into account the anticipated scope of injury and illness for the participants and potentially spectators and staff. Injuries are common during expedition-length adventure races, although the majority relatively minor, and few require evacuation or withdrawal from the event. At the 2005 World Adventure Racing Championships, 2.5 injuries per 1000 race hours were reported. During the event, 28 of 42 injuries were lower-extremity soft tissue injuries. These were the most common injury to require medical care. There was no significant association of injury during competition with age, gender, pre-race injury, pre-race illness, days off, or training hours [5].

Similarly, findings from the 2002 and 2003 Primal Quest in Colorado and Lake Tahoe, respectively, also revealed the most common injury to be soft tissue (70 % and 48 %). Orthopedic injuries were the second most common type of injury. During both of these events, blisters were the most common injury requiring medical care [3].