“Let me win, but if I cannot win, let me be brave in the attempt.”
Special Olympics athlete oath attributed to Eunice Kennedy Shriver
“The best way to find yourself is to lose yourself in the service of others.”
The world came to Los Angeles, CA, for the Special Olympics World Games (SOWG) in the summer of 2015. Current Sports Medicine Reports dedicated several articles to the preparation for the games and medical care leading up to and during the event (1,2,9,10). Careful attention in the medical plan was considered to address special needs of the intellectually and developmentally disabled (IDD) athletes participating in the Special Olympics. A higher number of medical problems were expected in this population compared with other large-scale sporting events. However, there is limited epidemiological data on the Special Olympics in the medical literature.
This article will review the outcomes from the SOWG and where the planning and anticipated events proved to be true and fell short. We outline the required adaptations to those events during the games.
The SOWG had 6,221 athletes registered, and approximately 3,000 coaches and delegates from about 170 countries participated (6). Competition was held between July 25 and August 2, 2015, at six venues across the Los Angeles area. The major venues included were the University of California Los Angeles (UCLA), the University of Southern California (USC), Long Beach, the Los Angeles Convention Center, Griffith Park, and Balboa Park in Encino.
Organizing the multiple stakeholders participating in the medical provision began almost 2 years before the event. Results from previous games were reviewed and some significant differences were noted for the SOWG, including the presence of the two Olympic Villages and the need to have medical personnel at widely spread events. There also was a desire to provide medical care focused on the needs of the athlete, with special attention to the specific medical needs of those with IDD. A medical advisory committee was formed consisting of interested parties from Kaiser Permanente, USC Keck School of Medicine and USC Administration, UCLA Medical School and Administration, Western Medical School, Children’s Hospital of Los Angeles (CHLA), Los Angeles Fire Department (LAFD), Los Angeles Police Department (LAPD), Los Angeles Public Health Department (LAPHD), and members of the Games Organizing Committee of the SOWG.
Test Games at USC 2014
It became apparent that there would be a need to test some of the medical plan before the SOWG 2015 games. Special Olympics Southern California (SOSC) holds the Summer Games yearly in June at Long Beach State University. With the support of their leadership and team, it was decided to hold test games at the USC site in the summer of 2014. In addition to the usual SOSC athletes, several hundred international athletes and delegates were invited to attend. This gave our team the opportunity to become familiar with the venue, work on trying the medical plan, and work with other agencies such as the LAFD, LAPD, USC Public Safety, and the USC Emergency Department staff that would be providing care during the SOWG in 2015.
There were several recruitment pathways for medical volunteers that helped in creating a robust medical presence but also led to some logistical issues.
SOWG hired a vice president for Medical Operations to help coordinate the medical volunteers. Medical volunteers were recruited through SOWG, medical stakeholders, local medical schools, local residency, and fellowship programs as well as through internet advertising.
Kaiser Permanente, as the official health partner, recruited physicians from our medical group. As part of the agreement, the background checks (required of all volunteers), uniforms, and training for our participants were provided by Kaiser Permanente. Uniforms and background checks for other medical providers were provided by SOWG.
Residents and fellows in training also were recruited from programs across Southern California, including many Kaiser Permanente residency and fellowship programs, Loma Linda University (LLU) Family Medicine Residency, and others.
In addition to providing typical sports medicine sideline care to athletes in 26 sports over 8 d of competition, the medical team was responsible for care of the athletes and delegates from arrival to departure. It also was necessary to plan for overnight medical care at the two Olympic Villages (USC and UCLA).
Special events such as the opening and closing ceremonies and some social events also required a medical plan and presence, with opening ceremonies planning made more complex by the attendance of one of the honorary co-chairs, First Lady Michelle Obama.
Healthy Athletes Program
In addition to the athletic events, Special Olympics provides screenings for athletes through the Healthy Athletes program, which includes preparticipation screenings (MedFest), dental care (Special Smiles), vision (Opening Eyes), audiology (Healthy Hearing), podiatry (Fit Feet), physical therapy (FUNFitness), and preventive medicine (Health Promotion). All athletes are encouraged to attend the Healthy Athletes program during the games. This will be discussed later in this article.
Communication plans included cell phone, text messaging, Web-based meetings, instant messaging, internet cloud-based file sharing programs, radios, and e-mail. There also were issues and plans around translation services for the many languages anticipated. In addition, training was provided to promote appropriate medical provider communication with individuals with IDD. Prior experience with long events demonstrated problems with missed calls due to loud ambient noise and dead phone batteries. As such, ear covering headsets were used for the radios during the opening and closing ceremonies. Medical team leadership was provided with neckband Bluetooth headsets during the games that vibrated when receiving calls. In addition, backup phone batteries were available.
Medical records for the test games and World Games were a modification of RaceSafe™, an app designed for medical care organization, communication, and documentation at mass participation events. Before the SOWG 2015 Los Angeles Games, the personal medical details of all athletes participating in the Los Angeles World Games were imported into RaceSafe™ from the Games Management Software, which is used to register each athlete for the World Summer Games. These data include diagnosis, medications, allergies, special needs (e.g., wheelchair), country and delegation information, and emergency contact details.
Modifications to the software included the ability to record many non-sports-related medical problems, such as seizures and diabetes. It also allowed the medical team to track possible communicable diseases by recording fever, vomiting, diarrhea, and rash and reporting the results to the medical leadership and the public health department.
In addition, important information from the preparticipation evaluation forms, such as medication lists and the presence of medical problems common in this population, also were recorded so that these details would be available to all medical providers on their cellular devices.
Medical records sent from delegations were reviewed for completeness regarding the medical conditions. There was limited information provided by the teams regarding vaccination status.
The medical team worked with LAPD, LAFD, USC Public Safety, Los Angeles World Airports, LAPHD, USC Medical, UCLA Medical Staff, UCLA emergency management, CHLA, and others to create emergency plans for the athletes, staff, and spectators during any point in their participation. These included medical plans for minor to severe issues in all the locations and during transportation. In general, plans for medical emergencies were kept within our communications system as much as possible. For example, on the USC campus, we had first responders, LAFD, and emergency ambulances with American Medical Response on the campus and ready to dispatch. Calls to 911 could delay response because it had to be communicated into our local emergency operations center from the 911 system. On the other hand, emergencies that occurred during transport on chartered buses required a first response by the usual emergency response (911) system. Special plans were created for the opening and closing ceremonies.
SOWG leadership, volunteers, and medical staff were instructed on the medical response communications plan. There were still calls to 911 made from the campuses, but with our communications and careful planning with local agencies, no delays in response were noted during the test games in 2014 or SOWG 2015 events.
A unified command post (UCP) with all of the above representatives was established for the 2015 Games at a location in downtown Los Angeles (Fig. 1). The medical command post was colocated in the UCP and staffed by administrative personnel and physicians from Kaiser Permanente daily from 7 a.m. until at least 9 p.m. and most nights until midnight. Medical leadership was available by phone and the main UCP was staffed around the clock with representatives of LAFD and LAPD.
Communications With Teams
A meeting was held in early January 2015 for the heads of delegations (HODs) from many of the represented nations. There was the opportunity for the medical staff to present important points in the medical plan and allow for input and questions from the HODs. The meeting was held after a well-publicized measles outbreak at a local tourist attraction (11). The medical staff took the opportunity to recommend that vaccinations be up to date and that there would be a reporting system during the games to monitor for infectious diseases in cooperation with the local health department. The medical leadership also communicated the need to complete accurate preparticipation medical evaluations and submit them for review and for data entry into our medical record system and concerns about the risk of heat-related injuries due to the expected weather in Southern California.
These requests were followed up with e-mails to the delegations and delegation team physicians.
Kaiser Permanente, as the founding champion and official health partner, had agreed to help train medical providers in the care of the Special Olympics athletes and sideline medical care. A symposium was created and held in June 2015 with presentations on sideline emergencies, care of sideline traumatic injuries, medical conditions common in the Special Olympics athlete, and communicating with those with intellectual disabilities. In addition, the medical plan was presented to more than 450 physician volunteers who were participating in the games. Electronic learning modules were set up for volunteers unable to make the live symposium. These were later gifted to Special Olympics for use at future events.
Sideline Care During the SOWG 2015
The sideline care for the 26 sports across multiple venues had a tiered approach. On the Fields of Play (FOP), the medical staff always included a physician along with nurses, athletic trainers, and first-aid and administrative personnel. Each field had a basic medical supply bag, cots, well-marked red tents, and signage.
Every member of the medical staff was designated by a red shirt with MEDICAL in white letters across the back and wore credentials to allow him or her access to all fields and venues. Medical staff had wide access across the games, as a medical event could occur at any location. They were instructed, however, not to “abuse” their credential and go to places they were not needed.
We provided bright green medical shoulder bags with basic medical equipment to all physicians to make them more identifiable in a crowd. Many games sponsors used red as their primary colored shirt, and the green bags helped observers identify the medical provider.
The tiered approach included the first response by a physician of any specialty who had been through the training program for the games. We ensured that there were primary care, urgent care, or emergency physicians locally available on the team. At each venue (UCLA, USC, Long Beach, Griffith Park, Los Angeles Convention Center, and Balboa Park), the medical teams were backed up by a supervising sports medicine physician and a sports medicine consultant who were available to go to the FOP if needed.
Emergency physicians staffed clinics at USC and UCLA to evaluate athletes that needed further care or diagnostic laboratories or x-rays. Any transports from the venues were coordinated through the UCP located in downtown Los Angeles.
Opening ceremonies held at the Los Angeles Memorial Coliseum required special planning. The First Lady of the United States, Michelle Obama, attended, requiring special plans to be compliant with the needs of the Secret Service. Medical supplies were prestationed at the coliseum to allow for security sweeps. The event was televised live on ESPN, and there were several entertainers and carefully timed events. The athletes assembled in the Los Angeles Sports Arena near the coliseum hours before the event and were entertained and fed at that location. A medical staff was present at both locations and for the parade of athletes.
In addition to the standard medical care team, a tactical medical course was provided for many of our physicians to instruct them on the use of tourniquets, chest seals, and bandages and to familiarize them with emergency response from law enforcement and fire rescue in case of a serious multicasualty event.
There also were mental health workers and “quiet rooms” at both venues in case of anxiety or the need to avoid the noise and stimulation at the ceremonies. These were successfully used at both venues for the opening and closing ceremonies (Fig. 2).
There were 3,280 medical incidents between July 21, 2015, and August 3, 2015 (Fig. 3).
There were 47 transports to local emergency departments and nine hospital admissions involving athletes participating in the World Games. There were 142 medical transfers to the Poly Clinics at Student Health Centers on the USC and UCLA campuses.
Medical incidents began with the arrival of the athletes on July 21, 2015, and reached a peak of 405 incidents on July 28.
Overall, 72.4% of incidents involved athletes participating in the World Games and 27.6% of incidents involved nonparticipants such as coaches, delegation members, volunteers, members of the public, etc.
The sports with the most injuries were as follows: 1) football/soccer, 2) athletics/track and field, 3) basketball, 4) swimming, and 5) volleyball. These also were the sports with the largest numbers of participants. The highest rate of injury (per athlete participant) was in softball, where 111 injuries were recorded in 140 participants. The lowest rate of injury was in table tennis, with 13 injuries in 200 participants. Data are still being evaluated to determine the rates per exposure, but these are limited by limited data on individual’s participation per day and the amount of time an athlete participated per practice and competition.
The most common complaint was fatigue and headache, which were both twice as high as the next two complaints of abrasions or pain.
The Los Angeles County Department of Public Health was interested in symptom surveillance for possible infectious disease outbreaks and asked the medical staff to monitor for fever (44 cases), rash (28), vomiting (28), diarrhea (8), and cough (44) specifically. There were no symptoms from any venue that had more than three events reported on any of these specific symptoms, suggesting that there were no outbreaks or patterns of concern.
Seizures are a common serious medical condition in Special Olympics athletes. There were 20 recorded athletes treated for seizures, with only four requiring follow-up in the hospital or emergency department.
Concussions are difficult to manage in this cohort of athletes because many have preexisting problems with balance, memory, and cognitive issues, as well as potential language differences. Those with suspected concussions were evaluated by a sports medicine physician or other clinicians trained in concussion management. A neurology consultant with special interest in concussion was available for complex cases. There were 26 reports of concussion.
The most common injured area was the knees, followed by the ankles and feet. Least injured areas were the pelvis, abdomen, and chest.
The Healthy Athletes program at the 2015 SOWG was record setting. Almost 89% or about 5,500 of the athletes who attended the games underwent screening in the Healthy Athletes program.
MedFest provides preparticipation evaluations for Special Olympics athletes. Because all athletes required examination in their home countries before the SOWG, MedFest was organized to help evaluate any gaps noted in review of the medical forms provided to SOWG. Some of these gaps were managed by contacting the delegations before arrival to the games, but some issues were not completely addressed. Because MedFest evaluations were not included in our data from RaceSafe™ or the other Healthy Athletes data, a detailed report regarding this activity is not currently available.
More than 5,000 athletes attended Fit Feet, had foot examinations, and were provided with properly fitting athletic shoes. The athletes had their ankles, feet, lower extremity biomechanics, and proper shoe and sock gear evaluated (3).
Comprehensive eye examination and 1,300 pairs of properly fitted eyeglasses were provided in the Opening Eyes clinic, which provided vision and eye health screening in partnership with the Lions Club International Foundation (8).
In Healthy Hearing, 197 athletes were newly diagnosed with a need for hearing aids, and 322 hearing aids were distributed, and free hearing screenings designed to ensure proper audiological care for Special Olympics athletes. Led by volunteer professionals, Healthy Hearing provided tests for ear wax and inner ear health (6).
Special Smiles provided comprehensive dental care to more than 600 athletes with free dental screening, oral health information, and instructions on proper brushing and flossing techniques. The athletes also received preventive supplies, such as toothpaste and toothbrushes (7).
FUNFitness is a physical therapy screening program that is designed to assess and improve physical strength, flexibility, and balance. The screenings also educate athletes and parents on the importance of staying physically fit and flexible and provide a hands-on opportunity for participating Special Olympics athletes to learn more about physical therapy (4).
There was a comprehensive health promotion screening that offered health information and advice in the areas of nutrition, sun safety, bone density, tobacco cessation, and physical fitness (5).
Welcome and onboarding (Los Angeles Airport and Loyola Marymount University)
During the 2014 Invitational Games, members of the medical staff were present at the Los Angeles Airport (LAX) for rapid screening of the 200 international athletes as they arrived. The athletes were then transported to Loyola Marymount University (LMU) where they would check in. The LAX medical team would notify the LMU medical team of any significant issues so that they were prepared to respond upon arrival. There were no significant events at LAX in 2014.
In 2015, paramedical personnel from LAFD replaced the onsite physician medical staff because the firefighter paramedics already had clearance to be inside the security perimeter of the airport.
Athletes and delegates were still brought to LMU for processing and to be transported to the Host Towns, where they were spending a few days before the Games to acclimatize to the weather and time zone changes. There were some transportation issues that caused delays of the athletes at LMU, keeping them from moving on to their Host Town accommodations. They were provided food, water, and sleeping areas at LMU. Medical staff was present overnight, which was an unanticipated need during our planning.
Several athletes needed attention, mainly in helping them adjust the timing of their diabetes and seizure medications due to time zone changes. One athlete had anxiety issues, which the medical staff handled in discussion with our team members and her parents/caregivers. She later participated in the games without problem. One athlete had a seizure with a prolonged postictal state, requiring transport to a local medical center by LAFD paramedics.
Recruiting medical volunteers for such a large event was challenging. One successful approach was recruiting medical residents from local programs. A good illustration is how LLU Family Medicine Residency approached the issue. Preparing for large-scale participation by resident physicians posed particular challenges, especially with regard to institutional sponsorship, credentialing, education, and scheduling. Approximately 18 months before the start of SOWG, the medical director and vice president for Medical Operations invited family medicine residencies (faculty and residents) to participate in the games. More than 30 LLU Family Medicine faculty and resident physicians served on the medical response team for the SOWG. The building blocks for resident participation in SOWG can be outlined with the phrase “obtain, train, and sustain.”
The first step for participation was to “obtain” permission from the sponsoring institution (LLU) to participate in the games. By obtaining the SOWG medical coverage dates over a year in advance, the resident schedules were able to be adjusted to minimize any disruption to patient care on the inpatient hospital and outpatient clinic teams. First year residents (who do not yet have state medical licenses at that level of training) were paired with licensed residents, and attending physicians supervised groups of those dyads. The SOWG medical volunteer organizers obtained and compiled the needed data on each physician in the residency at one time for credentialing and arranged for this group of physicians to be assigned to work together at the same SOWG venue.
The second step for participation in the games was to “train” the residents and faculty about the common medical conditions and sideline medical care for the Special Olympics athletes. Each of the residency physicians completed the online training modules provided by Kaiser Permanente and participated in the sports medicine training for SOWG at the residency program. They also received training in advance for how to electronically document medical encounters in real time at the SOWG during sideline care on RaceSafe™. At SOWG, the physicians were provided with standardized medical kits to use on site and instructed on their contents.
The third step for resident participation was to “sustain” the training and energy during the year leading up to the games while the residents were busy fulfilling their residency requirements. This was accomplished with periodic training tip reviews for SOWG, news briefs about the upcoming games, preparing to be part of a SOWG Host Town, watching heart-warming videos from Special Olympics, using social media, and interacting with local Special Olympics athletes. After volunteering at the SOWG, the residents and faculty from LLU Department of Family Medicine described the event preparation as “extremely useful” and the experience of volunteering at the SOWG as “amazing” and “inspirational.”
Residents from Kaiser Permanente and residents and medical students from USC, UCLA, Western University, and other programs also participated with similar preparation.
We anticipated heat problems during the planning of the SOWG. It became evident that the plans put into place were likely to become overwhelmed, and Kaiser Permanente arranged for increased tents and cooling stations as well as increased warnings with onsite medical staff and with teams with the highest risk for heat illness (mainly football/soccer). Close monitoring of the venues was done, with reports of temperature and humidity levels sent to the UCP on an hourly basis. There was a consultation with a warning coordination meteorologist from the National Weather Service in the UCP to help predict the changes in weather. These predictions were discussed with representatives of the games to determine whether any schedule changes would be in order. Supplies of fluids and ice to the venue were increased. There were no significant heat-related illnesses reported, and no events were cancelled or postponed (Fig. 4).
Chances of thunderstorms with concerns about lightning were less likely to occur in Southern California. Again, with the help of UCP and the weather service, evacuation plans were made. There were no storms requiring activation of these plans during the games.
The SOWG provided many tangible and intangible opportunities for medical providers. Certainly, typical sports medicine skills are needed to care for this large number of athletes during this international event. Interaction with law enforcement, fire rescue, public health, and multiple other agencies was established and will continue to be a great resource in future sporting and other events, such as disasters and large community gatherings. Thanks to an improved understanding for those with intellectual disability, the removal of barriers to medical care has been evident since the event.
“I think everyone should volunteer for Special Olympics because if you give them one minute of your time they’ll give you their heart.”
Dustin Plunkett, Special Olympics athlete and Global Ambassador
The authors would like to thank Anthony Luke, MD, FACSM, and Martha Brewster, practice care leader, Kaiser Permanente, administrative logistics director, SOWG 2015, for their help and assistance with this manuscript.
The authors declare no conflict of interest and do not have any financial disclosures.