THE ROLE OF THE SPORTS PHYSICAL THERAPIST-MARATHON EVENTS

Abstract

The role of the Sports physical therapist (PT) as a part of the sports medical team at marathon-type events varies widely. The PT can assume the role of an emergency medical responder (EMR) whose primary role is the management of the athlete in emergency type situations. The role of the EMR extends beyond the care of the athlete to the care and safety of the spectators. In this role, the PT must be prepared to handle any type of emergency situation, which may occur from medical conditions to acute orthopedic/sports injuries, to medical conditions which may be found in the participants of the race or the spectators. Additional roles of the PT can be in pre-race education, pre-participation screening/physicals, and other concerns by the participant related to injury prevention. Regardless of the role assumed by the PT, prior planning is essential for the safety, security, and maximal performance of the participant and to make the race enjoyable and safe for everyone.

Level of Evidence:

5

INTRODUCTION AND BACKGROUND

Long distance running, specifically Marathon distance running (26.2 miles) has increased significantly in the past 30 years from 25,000 marathon runners in 1976 to more than 470,000 runners in 2008,¹ to 551,811 runners in the 570 marathons that were held in the U.S. in 2011,² and a small decline in 2012 to 487,000 participants.³ (Figure 1) As numbers of marathon events and participants generally increase, the incidence of emergency situations would be expected to increase as well. It is estimated that 6-8 runners in the U.S. die each year while competing in marathon events due to cardiac disease, physical, and environmental factors.⁴ All medical personnel assigned to provide assistance to runners and spectators must be properly trained in first aid and emergency care including CPR and automated external defibrillator (AED) application. AEDs should be placed throughout the racecourse with appropriately trained individuals in attendance.⁵

Figure 1.

Marathon participant (Photo courtesy of Kari Brown-Budde).

The role of the Sports Physical Therapist (PT) as a part of the emergency medical team at marathon events concentrates on the primary responsibility of the Emergency Medical Responder (EMR) or First Responder. In many instances, the PT assumes the role as “most medical” or the individual present at the site of the emergency with the highest level of medical training. By assuming this role, we as Sports PTs, have a responsibility to the participants as well as those spectators in attendance at the event. The athletes and the spectators expect a safe environment in which to compete and enjoy the event. Regardless of athlete or spectator, we have a responsibility to manage any emergency situation which may occur immediately before, during, or after the event, and continue to provide care until every injured individual is released from on-site medical supervision.

PRE-MARATHON RESPONSIBILITIES OF THE SPORTS PT (PRE-RACE PLANNING)

In addition to the role of First Responder at events, the PT can play a role as a member of the sports medicine team by participating in injury prevention and education.⁴ Pre-race education of participants in appropriate training protocols, pre-participation screening, and other considerations can be advantageous. These educational interventions can affect the health and well-being of the participant and assist in prevention of a medical emergency during the event. Planned strategies to maximize the participant and spectator safety in environmentally stressful conditions (i.e. lightening emergencies, acclimatization) as well as the use of appropriate clothing, hydration, and nutritional practices are also beneficial. Pre-race investigation of the race course to clearly mark or reduce any hazards will decrease trip/fall risks for the participants as well as for the spectators.^5,6 Cooperation with race officials to minimize spectator hazards is another consideration. As a provider of emergency medical services, we must coordinate our coverage with the local emergency medical and security services. It is impossible for the emergency medical services to be everywhere at all times, therefore radio communication is essential.

EMERGENCY ACTION PLAN

Prior to the event, it is imperative that an emergency action plan is in place that outlines the roles and responsibilities of the PT and all team members who could be called upon in the event of an emergency. Prior to the actual race, the PT must provide (or be provided with) an emergency kit, two-way communications (i.e. cell phone with emergency numbers), and an AED.⁴ (Table 1) For suggestions regarding contents of a proposed emergency kit, please refer to Appendix A. In addition to outlining the communication and emergency response kit, the emergency plan should include identification of the personnel to serve on the sports medicine team with the PT, the needed and available equipment, the location of the equipment is not in every aid station, the mode of available transportation and the plans of action for common sports injuries for the particular venue.⁴ (Table 2)

Table 1.

Components of the Emergency Action Plan for Marathon Coverage.

Identification of the personnel involved in sports medicine coverage

Establishment of a communication system and plan to summon emergency care

Mode of emergency transport from the marathon/ race site

Outline of responsibilities/duties for each member of the sports medicine team

Triage procedures for mass casualties at the event

Table 2.

Common Plans of Action for Marathon Coverage.

NOTE: This is not an all-inclusive list and additional plans of action should be developed upon review of specific venue by the sports medicine team Blister Care Injury Prevention (e.g. venue hazards, weather related events such as lightening heat) Heat Illness Management Cardiovascular emergencies Pulmonary emergencies Diabetic emergencies Electrolyte Imbalances (e.g. hyponatremia)

THE EMERGENCY CARE TEAM

The sports medicine team providing coverage at a marathon event could include a physician (either Medical Doctor or Doctor of Osteopathy), Registered Nurse (RN), Certified Athletic Trainer (ATC), Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), massage therapist, and a chiropractor. Each aid station must have fluid replacement, (Figure 2) and depending on the event and it's organization, most aid stations should have an individual who can administer intravenous fluids.⁷ Commonly, insufficient numbers of trained medical providers are available to meet the all medical needs due to the large geographic area covered by the event. Event coordinators may choose to place some medical providers on bicycles or in golf carts in order to cover larger areas and decrease the time necessary to reach the ill or injured individual. Pre-hospital care must be administered at the site of the injury or illness unless the scene is unsafe. The individual must then be transported to a medical tent staffed with physicians and nurses trained in emergency care prior to transfer to a hospital emergency room. This can, on occasion, require air transport by helicopter. The call for air transport may be made by the PT, but more often, the call is made by physician or EMS/Law Enforcement person who is in charge of the scene.^7,8

Figure 2.

Runner receiving water at an aid station. (Photo courtesy of Matt DeWald)

EMERGENCY CARE

Emergency care begins with safety at the scene for both the spectators and the participants. Complete scene safety is extremely difficult if not impossible to achieve was evident during the recent events at the 2013 Boston Marathon. Scene safety is everyone's responsibility, but primarily the responsibility of the event security staff. Coordination with the designated security staff is necessary in order to establish scene safety prior to, during, and after a medical emergency.^7,8 Once scene safety is established, individual assessment of “runner down” of “spectator down” is based on whether the individual is ill or injured. The initial assessment begins with the assessment of the individual's respiratory status including airway and breathing, followed by assessment of circulation, as well as their level of consciousness. Additionally, severe bleeding must be evaluated and controlled. Threats to life and limb must be the primary concern for the PT in all emergency situations. Secondary concerns are related to the overall medical, neurological, musculoskeletal status of the individual along with changes in athlete status during evaluation and emergency care. Follow-up care for these individuals includes calling for advanced medical care, reevaluation of respiratory and cardiac status as well as changes in the individual's level of consciousness, followed by a head-to-toe survey. Questioning the conscious individual related to symptoms, allergies, medications, past medical history, last meal and event preceding this situation (SAMPLE History) would also be indicated.⁹ (Table 3)

Table 3.

“SAMPLE” examination questions.

S- Symptoms

A-Allergies

M-Medications

P-Past Medical History

L-Last Oral Intake

E-Events Preceding this Event

WORST CASE SCENARIO

In the overall aspect of planning, one must keep in mind the “worst case scenario” factor. With large crowds, and the possibility of a large number of casualties, who is responsible for triage, who will contact local hospitals, who will call in additional rescuers, and who will deal with the family members?^6,8 It is virtually impossible to prepare for all unforeseen emergencies, but prepare for the worst and deal with what is presented to you during the event. Prepare the best you can and have a ready and well-designed communication plan in place.

CONCLUSION

The role of the Sports PT as a part of the sports medical team at marathon-type events varies widely. The PT can assume the role of an EMR whose primary role is the management of the athlete in emergency type situations. The role of the EMR extends beyond the care of the athlete to the care and safety of the spectators. In this role, the PT must be prepared to handle any type of emergency situation which may occur from medical conditions to acute orthopedic/sports injuries, to medical conditions which may be found in the participants of the race or the spectators. Additional roles of the PT can be in pre-race education, pre-participation screening/physicals and other concerns by the participant related to injury prevention. Regardless of the role assumed by the PT, prior planning is essential in the safety, security, and maximal performance of the participant to make the race enjoyable and safe for everyone.

Appendix A - Potential Equipment and Supplies Recommended by American College of Emergency Physicians- EMS Committee 1995-1996

• Elastic Bandage (all sizes)

• Flashlight

• Airways

• Alcohol Swabs

• AMBU bags

• Spine Board

• Band‐aids (all sizes)

• Batteries

• Benzoin

• Betadine

• Blankets

• Burn Dressings

• Cardiac Monitor

• Cell phone

• Cervical collars

• Clip boards

• Cots

• Cotton applicators

• Cotton Balls

• Crutches

• Defibrillator

• EKG

• Eye Patches/Shields

• Gauze Pads

• Gloves (sterile and non‐sterile)

• Head Immobilization Device

• Ice/Ice Packs

• IV's/IV poles

• Kling Dressings (all sizes)

• Opthalmoscopes

• Otoscopes

• Oxygen Masks and Nasal Cannula

• Oxygen tank with regulator

• Oxygen Saturation Monitors

• Patient ID Braclets

• Peak Flow Meter

• Pens/Paper

• PIllows

• Pocket Mask/Face Shield

• Radios (hand held with appropriate frequencies)

• Razors

• Reflex Hammer

• Refrigerator/ Coolers

• Ring Cutter

• Safety Pins

• Scissors

• Sanitary Napkins

• Scoop Stretcher

• Sheets

• Slings

• Soap/Hand Sanitizer

• Sphygmomanometer

• Splints

• Steristrips

• Stethoscopes

• Suction Machine

• Suction tips/catheters

• Surgical equipment‐ cut down/chest tubes

• Triangular Bandages

• Vaseline (jar and gauze)

• Water (rehydrating fluids)

• Suture kits

• Tampons

• Tape (all sizes)

• Telemetry Equipment

• Telephone access (cellular)

• Telfa

• Thermometers

Appendix B: Potential Equipment for Aid Stations

Reclining chair or table

Water Bath- recommended for the final 6 miles of the race at venues known for heat challenges

AED

Ice bags

Blister Kit (s)

Hand sanitizer

Glucose replacement

Electrolyte drinks

*Note: The final aid station should have the capability of administering intravenous fluids.