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Preparing for the Surge

Perspectives on Marathon Medical Preparedness

Chiampas, George1; Jaworski, Carrie A.2

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Current Sports Medicine Reports: May 2009 - Volume 8 - Issue 3 - p 131-135
doi: 10.1249/JSR.0b013e3181a8c43a
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While mass participation endurance events continue to increase in number and popularity throughout the world, it is well-recognized that the potential impact of the event on the community and its resources needs to be accounted for in the planning and implementation of such events. This concern becomes more significant when faced with the added factor of extremes in weather and/or the threat of catastrophe. Our first-hand experience with the extreme heat and humidity of the 2007 Chicago Marathon, resulting in the need to cancel the event mid-race, provided us with additional knowledge in the management of a mass participation event in the face of adversity. During our particular race, not only did we have to address the usual participant medical issues, but also be cognizant of the potential added stressors that would be placed on various public health resources in the event of an increased number of casualities. This experience has served to enhance our medical event-planning for both the usual and customary days and in the event of a surge caused by either extremes in weather or other catastrophe.

The primary responsibility of the race medical director, in conjunction with the race director, is to plan and execute an event that is safe for all participants. A wealth of information exists that offers medical directors insight into the basics of implementing a medical race plan (1,7,8,16). Our experience in Chicago is somewhat unique based on the inordinately large number of volunteers and resources available to us. While most races may not have the capabilities described below, each race can take the key concepts discussed and apply them to their particular situation. The challenge one faces is understanding the limits within one's own community as to what a race can actually handle in the event that the unexpected occurs. Again, it is the responsibility of the race medical director to work closely with race planners and resources in the community to implement contingency plans for various scenarios that may present themselves during a mass participation event. The necessary adjustments to such items as the amount of supplies and the number of volunteers need to be determined before the actual event in order to provide a seamless transition from normal race day operations to that of emergency operations. Having a fully operational emergency action plan is an essential piece for the successful execution of a mass participation event.


We have found that an extremely beneficial approach to assist in the planning of our event is to use the expertise of multiple agencies within our community. Through the assistance of both our local police and fire departments, the key race organizers were able to receive training in emergency operations management developed by the Federal Emergency Management Agency (FEMA). The training introduced us to the concepts of NIMS (National Incident Management System), ICS (Incident Command Systems), and UC (Unified Command). NIMS was originally developed by the Department of Homeland Security to standardize the approach to incident management and response. ICS is the standardized on-scene incident management concept designed to allow responders to adopt an integrated organizational structure that matches the complexity and demands of any single incident or multiple incidents without being hindered by jurisdictional boundaries. An Incident Command System (ICS) may be expanded into a Unified Command (UC). The UC is a structure that brings together the "Incident Commanders" of all major organizations involved in the incident to coordinate an effective response while at the same time carrying out their own jurisdictional responsibilities. The UC links the organizations responding to the incident and provides a forum for these entities to make consensus decisions (17).

Experience with the Incident Command System (ICS), as detailed by FEMA, is imperative to ensure efficient operation of the system in a true disaster scenario. Large mass participation events, such as a marathon provide a more controlled environment in which to implement the ICS. These events require the coordination of public, private, and medical agencies and need effective communication. In a way, these events are "pre-planned disasters." Every marathon and mass gathering has a known number of "casualties," or people requiring medical assistance. This number ranges from 2% to 10%, depending upon variables such as event size, duration, and weather conditions (5,11,15). During situations where the casualty number rises, there is the potential for various agencies or departments to become overwhelmed if resources are not allocated appropriately.

In the last decade, FEMA has designed and advocated for a new system of coordination in the event of a disaster that uses an unified command structure to communicate between involved responders. This new system, if implemented properly, can avoid duplication of tasks and misinformation, and it ultimately can limit casualties. Rather than having all of the various agencies working independently on race day, it seemed logical to implement a unified command approach to our marathon organization. Through the use of UC, leaders from agencies such as the Red Cross, the Office of Emergency Management, Chicago Police, and Chicago Fire work together with our staff to direct our emergency action planning and implement strategies in the ordering and releasing of resources. On race day, these agencies sit side by side in our command post, adjacent to the main medical tent, and serve as the headquarters for communication and resource allocation. By implementing such a UC system for the marathon, we have been more successful in using our available resources and creating strong links between many city and state departments.

Preplanning/Preparation Phase

The marathon preplanning phase is the most task-filled aspect of the entire preparation process. It is a step-wise process occurring over several months, immediately following the previous year's race, that involves key leaders and operations personnel to collaborate and design a plan and several contingency plans for the day of the marathon.

For us, it initially begins with our key staff members, including the race and medical director, participating in Incident Command training. During this training, participants design mock Incident Action Plans (IAPs) for various incidents based upon NIMS standards. This training allows the staff to sit down with local and state Emergency Medical Services (EMS) to design a specific IAP for the event.


During this time period, the operations team, including the medical director, should dissect the course. An important consideration is the creation of diversion points along the course that have the ability to stop or divert runners. In addition, large spaces such as parking lots or fields should be identified to provide additional resources to runners, including fluids, nutrition, communication, and medical aid. Part of the planning process would be to situate these diversion points at or near aid stations to use existing personnel and resources with the ability to increase personnel as needed. Adjustments need to be made to account for changes to the course based on new construction projects or other alterations to the course from previous years.

When assessing your course, additional things to consider would be the development/improvement of staging areas for EMS, access and egress of ambulances from your aid stations, and the accessibility to water hydrants should the need arise. Discussions on the appropriate number of medical aid stations with the flexibility to increase those numbers based upon anticipated surges due to weather should occur early on in the process. These decisions should be based upon past experience with one's particular event as well as published data on expected rates of use (3,4,8,10,13). Finally, the creation of zones, or color coding the course, with a limit to the number of aid stations within a zone or color will assist in managing events and personnel in a more systematic fashion.


Communication among all race personnel, EMS, local hospitals, and participants is critical to help prevent and respond to incidents during race day. The preplanning phase allows for the securing of two-way radios, cell phones, or both to be used by those who will be working the event. Meetings and teleconferences throughout the planning phase allow for further development of communication tools and ideas for improvement.

The more difficult task is designing a communication tool for disseminating information to participants. In Chicago, we have chosen to use an Event Alert System (EAS), which is a colored flag system based upon that previously described in the American College of Sports Medicine's (ACSM) Position Stand on exertional heat illness in training and competition (1). The EAS was designed to improve communication with runners regarding anticipated weather condition changes or emergency situations (e.g., fires or gas leaks) occurring during the event. The key to the flag system is advanced implementation. Educating runners, volunteers, and EMS personnel via race Web sites, e-mail blasts, and table-top exercises well in advance of race day are just a few examples of its implementation during the preplanning stage of preparation.

Centralizing all communications to a UC center and use of the ICS also should be decided in the planning phase. This allows the event to move into the later planning phases with the understanding of the individuals involved and their roles on race day. In Chicago, the ICS is frequently used for events such as our annual Magnificent Mile Lights Festival as well as the 2008 Obama Election Night Presidential Rally. Because of the great comfort level of ICS within our city, the Chicago Marathon implemented NIMS-compliant ICS for the first time at the 2008 marathon.


In Chicago, our approach is multi-specialty in nature, providing onsite event medical care and preservation of the EMS system for the rest of the service area. Securing equipment to provide this care takes place months in advance. This includes onsite electrolyte blood testing, cardiac monitoring capabilities, automated electronic defibrillators (AEDs), and additional supplies to provide advanced medical care (6,9,12,14). The development of strong relationships with local companies and suppliers has allowed us to have access to some of the best equipment available.

Planning Phase

As the event nears, we move into our final planning stage. Two to three months before the race is where final adjustments to our preplanning stage are made. Having the tools and human resources readily available to do such adjusting allows for an easy transition from a normal race day to that of increased need.


During the planning phase, the number of aid stations and their sizes should be determined. One unique example in preparing for a surge is enlarging the initial fluid stations to help relieve an influx of large amounts of runners in the beginning five to seven miles. This allows better access to water and sports drink stations and potentially prevents overcrowding and an inability to obtain fluids. In preparing for a surge, having the flexibility to increase the number of medical aid stations in size and personnel, especially towards the last 6-8 miles where collapse may be more prevalent on a warmer day, can alleviate added strain on your medical personnel on the course. In addition, designating ambulance locations on the course and having the ability to move ambulances forward along the course as medical aid stations and zones close allows resources to be used best.

The planning phase also should designate hospitals closest to each of the medical aid stations and be within their designated zones to prevent overwhelming one particular hospital. These designations can be dispersed among EMS personnel via maps to assist on race day. We also use runner drop-out buses to transport runners who are unable to complete the course but do not necessarily require medical assistance. The number of these buses also must be adjusted in the event of adverse conditions.

Additional planning is required at this time to determine the best location and layout of the UC. Proximity of the UC to overall operations is critical in sharing and relaying information of course events in a timely fashion. Within the UC, a detailed layout of which agency is represented and exact positioning for ideal interaction is critical. As mentioned, our UC is adjacent to the main medical tent.


Communication among participants, spectators, volunteers, staff, and EMS personnel is the most critical aspect in managing a surge. This process takes months of preparation and requires the work of all involved to be successful. It begins by educating participants, volunteers, EMS, and staff about the EAS and how it would be used during a surge. Distributing the EAS via emails to all runners months and weeks in advance allows them to become familiar with this system before race day. Positioning announcers at aid stations can spur on runners in normal (green) conditions, yet also can be used to relay changes that may occur after the race has begun.

Running tips covering exertional injuries and medical issues also allow better education and training for the runners before race day. These tips can be placed on the marathon Web page and/or emailed to registered participants. During this time, education of all volunteers also is critical. Providing information about the course operations in an emergency avoids delays on race day. This can be accomplished via training sessions, group meetings, and informative emails. Some examples would be information on the presentation and management of exercise associated collapse, hyponatremia, and hyper- and hypothermia. This prepares all first responders and caregivers for issues specific to marathon medicine.

This time period also is when credentials, pertinent phone numbers, and communication devices are assigned. Creating a universal emergency number for the event is part of the Bank of America Chicago Marathon's standard operations. This number is dedicated for EMS response, and on race day it is located within the UC where telemetry dispatches ambulances and ALS bike or foot teams to respond to these calls. Key operations personnel numbers are assigned, including the emergency number, which will be displayed on all staff and volunteer credentials for race day.

An additional resource is the American Red Cross's new Patient Connection Program (PCP). The PCP provides a phone number that is communicated in advance and on race day for families trying to connect with runners. Events working with the Red Cross can disseminate information as to the location of runners based on their chip. The Red Cross will know if a runner is in a medical tent or has been discharged or transported to a local medical center.

Finally, creating a detailed map with locations and designations of the planned surge resources and disseminating to staff and participants enhances their overall understanding of the event. Reviewing these maps in advance helps to decrease confusion on race day.


While the majority of marathons do not encounter extreme conditions, preparing for and having the resources to manage a small-scale disaster is critical. In a large-scale marathon, the potential need to care for hundreds to thousands of participants is very real. At the Bank of America Chicago Marathon (BOACM), resources are secured for both a "normal" day while at the same time being prepared to trigger contingency plans based upon a change in the EAS. These plans are set in place during this period, including additional resources above and beyond our "normal" operations needs.

In preparing for the surge, additional resources must be in place to call upon if needed. These supplies would be spread across the aid stations, main medical tent, and the course. Increasing IV fluid capabilities, ice, cooling tubs, and the use of hydrants to create shower and sponge stations at predesignated locations are just some measures that should be considered. In Chicago, runner drop-out buses are available but increased in numbers based upon the EAS and become cooling or warming buses, depending upon the conditions. These buses will be supplied with fluids, nutrition, and additional cooling methods if warm conditions are occurring. The capability to cool or heat the medical tents also should be part of the planning session.

Rapid cooling measures are of essence during warm marathon events. Increased supplies of ice towels are distributed across the course and medical tents, while pre-positioned supply trucks with water bottles may be triggered by the EAS to supplement aid stations. Runners also may use the runner drop-out buses that, during warmer races, are positioned at each aid station to cool down or return them to the finish area.

In colder instances, buses can be heated and provide similar management. Initiating the cold plan would trigger more blankets and heaters for key medical areas. Warm broth is an additional measure used in the medical tent for re-warming.

Tracking weather conditions along a marathon may be very difficult and at times inaccurate. The use of wet bulb globe thermometers (WBGTs) may assist in providing accurate conditions in a timely fashion. One method is to have a device in each of the designated zones across the course and, at designated times, check the WBGTs and call these in to the UC. This information allows a better and more accurate measurement from the marathon course and can trigger changes in the EAS. Our race policy requires two zones to have changed to a different alert level before we will announce such a change on the course.

Implementation Phase

Course and communication

During the week of the marathon, there should be planned coordination between the agencies from UC on any new or additional information that may change the EAS. This can include weather updates or other local events that can impact a race day. If changes are known, information can be dispersed to runners and staff via email, handouts, and signs at the expo or media outlets. For instance, the BOACM experienced warmer than ideal conditions in 2008. Being prepared in advance allowed us to implement the previously discussed strategies to inform participants and volunteers well ahead of the actual race day. Decisions on race day are made by the Incident Commander (IC). This individual must have a full understanding of event operations as well as the ability to initiate preplanned triggers as incidents occur. The IC must be present within the UC at all times and work in conjunction with all parties involved. For our purposes, the IC is either the race or medical director, depending upon the incident. Communication to media of incidents during or after the event should be disseminated by the designated Public Information Officer (PIO).

In 2008, temperatures were forecasted for higher than ideal, and the EAS was set to yellow several days before the race. This level, and its message, was communicated to runners and staff via media outlets days in advance. It also triggered our heat contingency plan, and additional resources were put in place. Information on the event and the anticipated surge of more heat-related cases than normal was discussed with local receiving hospitals. Some of these hospitals increased staffing and set up cooling measures with preplanned resources to manage a higher than normal case load (Figure).

Event Alert System. From Bank of America Chicago Marathon 2008 Web site. Reproduced with Permission of Chicago Event Management.

On the day of the race, medical teams comprising of physicians, nurses, physical therapists, athletic trainers, and social workers are transported to their aid stations where they confirm their arrival and acknowledge the prepositioned supplies with the UC post. From there, they work with their individual aid station captains and zone leaders for additional resources and final details. When closing their aid stations, they may be reassigned to later stations or return to the main medical tent based upon need.

In the main medical tent, final setup and assignments of similar multispecialty teams are completed. Review of the EAS is performed again as well as introduction of key team members. Brief discussions are held on the preferred approaches to any anticipated medical issues that may be in abundance based upon current weather conditions. For instance, on hot days, we discuss steps to take in rapidly cooling a person.

The UC becomes the hub of operations on race day. Unified Command communicates via cell phones with personnel on the course in addition to using visual technology available on the course. The operation and event proceeds with a two-fold goal of providing an expedient response to runners while being vigilant to any possible effects it would have upon other participants, spectators, and the citizens of Chicago. This is led by the Incident Commander who, in our case, is the race director with the ability to transfer authority through the proper ICS channels if an incident were to occur.

Additional teams are mobilized in the finish area, where the majority of expected cases of exercise-associated collapse will occur (2,7,8). Sweep teams with wheelchairs are assigned blocks at the finish line. Elevated personnel, known in our race as deer blinds, utilize bull horns and flags to identify and point out downed runners to the sweep teams and/or EMS on the ground. The Code team consisting of critical care trained staff, along with EMS, is positioned at the finish line to respond to and identify runners in need of urgent medical care.

Various components of the medical teams described are used by several large-scale marathons and can be modeled to fit the scope and size of one's own event. In addition to the above medical teams, EMS personnel are positioned on carts, bikes, and foot to patrol areas of the course, specifically the finish area.

Triage and check-out areas are designated at the main medical tents to assess and assist in workload and flow of patients. During this day, the WBGT readings from the course are communicated back to designated staff within UC. Mid-race in 2008, the EAS was increased to red and communicated across the course via the preplanned measures that had been established months in advance. Yellow flags were changed over to red, and a prewritten script was relayed across audio capabilities at each aid station as well as by volunteers on the course. From UC, resources and events were constantly monitored, and the ability to shift resources and personnel was always available. Contingency plans went into effect, triggering the additional resources as described previously.

Upon completion of the marathon, the medical director must then account for all participants and their conditions. This is done by tracking any hospital transports, runners in medical tents, and drop outs. This information will be much more accessible with the preplanned organization discussed previously. Providing this information to the PIO is essential for a consistent and single outlet of medical information.

Post-race phase

In the weeks following the marathon, meeting with your key medical staff and UC agencies allows the opportunity for feedback on operational issues. This provides an open forum for all to share how things can improve for future preparation and implementation. Our key staff members debrief in the hours and days immediately following the race, while the larger group reconvenes about four weeks later. At the larger group meeting, data is shared on such aspects as the number of participants seen in the medical tents, number of transports, and number of hospitalizations. It is during this time that race organizers also can reach out to participants to ask for their feedback on race quality and concerns via e-mailor other means. Once feedback is assimilated, it also can be shared with the group to base future planning around.


As evident by the examples provided here, many steps are required to plan for the unexpected in a mass participation event or marathon. Having clearly defined roles and responsibilities during all phases of planning in addition to a well-thought-out incident action plan greatly will assist in the success of an event and the prevention of overwhelming a community. The BOACM has been fortunate to have the help of a very talented group of NIMS/ICS-trained personnel who have embraced our event and work hard to keep it running smoothly. Using the community resources available to you is a viable option in most cities, and one that should be considered in planning mass participation events. Through the diligent work of many, disasters may be curtailed or averted.


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© 2009 American College of Sports Medicine