Mass participation events including marathons and shorter road races, Nordic ski, bicycle, and triathlon competitions have been gaining unprecedented popularity with increasing participation in the United States. Running USA reports more than 17 million total finishers in road races across the United States in 2015 with more than 500,000 of those finishes in marathon races (1). The three largest marathons in the United States are the New York City, Chicago, and Boston Marathons, which in 2015 combined for approximately 113,000 finishers and close to 50,000 finishers in the New York City Marathon alone (1). As road racing participation continues to grow in popularity, the medical organization of these mass participation events must evolve to accommodate the growth. Participant safety, injury prevention, and medical treatment have always been at the forefront of race planning and medical preparation. The unfortunate Boston Marathon bombings in 2013 highlighted the large-scale public safety concerns that also must be addressed when planning a mass participation event. Marathon and other large sport events now require integration of local, regional, and federal agencies with use of public and private resources, and must follow regional and federal emergency protocol guidelines to optimize safety for the participants and the public. Public safety must be integrated into the management plan of large races and events as the potential for mass casualty events often hinges on the evolution of global and international relations. Our goal is to share the components required to prepare for a large marathon race using a unified command structure to reduce injuries, treat medical conditions with best practice guidelines, avoid hospital overload, and reduce the threat to public safety.
Mass Casualty Incident
A mass casualty incident is defined as an event which generates more patients at one time than locally available resources can manage using routine procedures (2). Marathon race management structure must be organized to reduce the likelihood of a mass casualty incident and avoid overwhelming the resources of the local emergency medical services (EMS) providers and hospitals. Large race organizations, such as the Boston Athletic Association, responsible for organizing the Boston Marathon and other Boston area road races, and other race organizations in other regions of the country regularly use the National Incident Management System (NIMS) and Incident Command System to build their command center infrastructure (3).
The Incident Command System was initially developed in the mid 1970s to coordinate the large number of resources required to manage massive wild fires in California. For many years, the fire service used some version of an Incident Command System to mitigate logistical and personnel problems, but there was never a formal system in place to manage multiple agencies. The dreadful experience of September 11, 2001, changed the landscape, and the U.S. government realized a unified system was essential to coordinate multiple agencies from different jurisdictions to implement an effective emergency response.
Under directives (Homeland Security Department 5 and 8) authorized by President George W. Bush, the NIMS system was created after the terrorist attacks of September 11. The Homeland Security Act of 2002 sanctioned the U.S. Homeland Security Department to further develop NIMS and set up the laws and regulations that are now in place for managing domestic incidents. The system is meant to guide a proactive approach to manage all threats and hazards regardless of cause, size, location, or complexity to reduce loss of life, property, and harm to the environment. It is intended for use by individuals, communities, and organizations in both the private and nonprofit sectors (4). The ramp up of NIMS created ten federal office locations to manage regional events throughout the United States (5). The most significant difference between the old and new NIMS formats was the recognition that emergency responders were not the only personnel needed in a mass casualty incident, and many agencies play a role in pre-event planning for potential targets and threats.
The incident command system provides a structure within NIMS to integrate a combination of facilities, equipment, personnel, procedures, and communications usually housed in separate organizations. The incident command group facilitates the five major functional response areas including command, operations, planning, logistics, intelligence and investigations, finance, and administration, enabling incident managers to focus on key concerns without sacrificing attention to any component of the command system. In the application of this system for marathon race planning, there must be effective and efficient integration of all public safety agencies, EMS, hospitals and emergency departments, personnel including medical staff and EMS personnel, and equipment management (6).
Integration of Public and Private Safety Agencies
A marathon should be planned as a potential mass casualty event to ensure appropriate resources are available to react to any threats that may arise. Medical, emergency, and security teams must develop a comprehensive plan to ensure quality medical care and optimal safety on race day. Community, state, and federal agencies should be involved in the planning. Local hospitals should be informed so they can coordinate their staffing and resources and develop triage and treatment protocols for race day. For example, in Boston, the Massachusetts Emergency Management Agency (MEMA) coordinates the preparation of federal, state, local government, and private agencies to respond to potential state emergencies and disasters (7). MEMA assists with planning the Boston Marathon by coordinating the regulatory and health systems across Massachusetts cities and towns. At planned meetings for local, state, and federal agencies, theoretical marathon disasters are discussed to brainstorm action plans for each potential scenario. The Boston Athletic Association, which organizes the Boston Marathon, optimizes public safety by building strong relationships and working closely with the fire department, local and state police, the Department of Public Health, and MEMA. These groups collaborate to develop comprehensive policy and operational plans that define their roles so the necessary resources can respond efficiently and effectively to any potential threat. Within the leadership group, there should be designated race managers who are aware of the higher level plan protocols and can activate an emergency response. While most volunteers and division leaders will not know the full details of the highest level plan protocols, all volunteers, division leaders, and medical directors should have easy access to the point persons responsible for activating an emergency response for actual or potential threats.
Understanding Local Race Factors
There are several factors that affect racers, injury rates, and the ability to respond to emergencies which vary from race to race. Major issues to consider are the weather, altitude, concurrent regional events, course terrain, course layout and distance, volume of runners, fitness levels of the participants, and acclimatization that may be required.
Race day weather is the most likely factor to affect runner outcomes with slower pace, increased medical encounters, and increased participant drop outs. Timing of the race in relation to the geographic location is an important consideration when planning the date of the race. For Northeast and Midwest locations in the United States, such as Boston, New York, and Chicago, the spring and fall seasons are more likely to deliver good running conditions and avoid extreme heat and cold, while winter season may be better in the south and on the west coast. However, outlier weather conditions may occur, so it is necessary to continuously monitor weather forecasts leading up to the race. The wet bulb globe temperature (WBGT) correlates with the risk of exercise based on environmental conditions and should be used to help determine race policies. It is calculated with the equation: WBGT = 0.7 × (wet-bulb temperature) + 0.2 × (black-globe temperature) + 0.01 × (dry-bulb temperature) (8), and the water content of the air is the major variable affecting heat transfer during exercise. The American College of Sports Medicine defines low-risk WBGT to be less than 65°F (18.3°C), moderate risk between 65.1°F and 72.0°F (18.4–22.2°C), high risk for all competitors between 72.1°F and 82.0°F (22.3–27.8°C), and extreme risk and recommendation for event cancellation at temperatures of 82.1°F (27.9°C) or higher (8). However, these WBGT levels are based on acclimated, fit young men and not the usual participant profile of a marathon. Although WBGT is used widely and adopted by many sports federations, it may underestimate heat stress risk when sweat evaporation is restricted under high humidity conditions (9), and humidity adjustment scales have been created to accommodate for high humidity weather (10,11). It is important to monitor the weather forecast because weather can significantly impact the number and severity of injuries and visits to the medical tent. The Boston Marathon heat wave in 2004 led to an increase in number of visits to the medical tents from its typical 2% to 4% of all runners to nearly 10% of all runners due to the unusually hot weather with temperatures reaching 86°F at the finish line (12). Races should account for increased numbers of nonfinishers both on the course and at the finish line if there is elevated WBGT on race day (13) and consider establishing a “do not start” WBGT level (14) based on the race’s capabilities of handling the anticipated volume of nonfinishers and medical encounters.
Heat and acclimatization
Acclimatization to different weather and geographical conditions is another factor in race outcomes. Participants should be educated about proper heat acclimatization recommendations if they are preparing for a race with higher temperatures and humidity than the area where they live. Although some temperature adaptations develop within the first week of training in the heat, it may require 6 to 10 d to achieve near complete cardiovascular and sudomotor adaptations, and a full 2 wk to optimize aerobic performance in hot ambient conditions (11,15,16). Highly trained athletes typically adapt more quickly than untrained or lesser trained individuals (17,18). A comprehensive emergency action plan for exertional heat stroke (EHS) with sufficient numbers of trained staff and on-site equipment for body temperature measurement and whole-body rapid cooling of athletes is required for all races as EHS can occur in very temperate conditions. Race planners also should consider scheduling races to start near sunrise to limit the exposure of participants to the hottest part of the day and to avoid midday heat in hot and humid environments.
The physiological effects of cold acclimatization in athletes are typically negligible for nonarctic conditions. Participants preparing for races in cold temperatures should be educated about proper race clothing with multiple removable layers. The medical team should have the medical resources to treat hypothermia, and if in deep cold, frostbite. Heated medical tents or shelters at medical treatment locations should be available. The increased ventilation of exercise in cold and dry environments results in airway drying and inflammation, which can exacerbate pulmonary conditions. Racing in these conditions may increase asthma exacerbations and cause exercise-induced bronchospasm in athletes who have no problems in warm conditions. Medical teams must be prepared to treat with nebulized bronchodilators, humidified air, and oxygen. The International Olympic Committee Consensus Statement on thermoregulation suggests that elite athlete competitions not start or continue with a combination of air temperature and wind speed (wind-chill) colder than −16.6°F (−27°C) (19).
Events held in high altitude environments 1500 to 3500 m (4900 to 11,500 ft.) require more participant education and planning. There are very few events conducted at altitudes above 3500 m other than the Leadville 100 that peaks at 4019 m. High-altitude environments have lower partial pressure of oxygen which causes alterations in physiologic functions associated with exercise. The physiologic responses and clinical symptoms of altitude illness begin to play a role in exercise performance and acute mountain sickness at 1500 m (4900 ft.) and become more prominent at moderate elevations greater than 2500 m (8200 ft.) (20). Acute exposure to altitude first leads to an increased ventilation rate causing a respiratory alkalosis and a resulting diuresis mediated by the renal system. This triggers other complex physiologic changes, all of which reduce endurance exercise performance. This altitude-induced diuresis occurs as an early stage of acclimatization within 12 to 24 hours of exposure and athletes should be aware of this to maintain a good hydration status (20,21). Medical staff and participants should be educated about altitude illness symptoms to monitor for including headache, nausea, vomiting, dizziness, weakness, anorexia, insomnia, dyspnea at rest, cough, decreased exercise performance, and the more severe symptoms of changes in mental status, ataxia, tachycardia, rales, wheezing, and chest tightness/pain. Organizers should consider special monitoring for populations at higher risk of altitude sickness, including obese, older, and pregnant individuals, younger children, and those with preexisting lung disease, anemia, and sickle-cell disease. In preparation for racing at high altitude, arriving about 2 wk before competition should allow time for acclimatization (19). For altitude sickness prevention, controlled ascent, acetazolamide, and, in certain cases, dexamethasone may be used (20). To treat symptomatic racers, medical teams should have proper resources including appropriately trained staff and sufficient supplies including medications and supplemental oxygen. If rapid transport to lower altitudes will not be possible, a Gamow bag should be included in the response kit.
Course layout and difficulty levels
When organizing the medical plan for a marathon race, the overall difficulty level of the race course and specific areas of challenging terrain must be considered. Hills increase the exertion required for runners and steep or long elevation changes may require specific medical tents and resources to care for those who are overly stressed by large elevation climbs. Course loops may require direction aids for the racers to ensure they follow the correct path at the intersections. These loop intersections also are ideal placements for medical stations because the higher foot traffic allows a greater opportunity to intercept injured runners as they pass these sites. Organizers should monitor road conditions and remove any hazardous elements if possible. In rainy or wet conditions, racers should be alerted about areas with slippery or rough terrain and medical staff should be readily available at those sites.
Volume of runners
The large volume of runners in marathon races and the associated spectators puts these events at higher risk of being singled out as a target for terrorist activity or demonstrations that increase the possibility of becoming a mass casualty event. When organizing a race, one must consider the expected volume of runners and spectators and enlist trained staff to control anticipated crowds throughout the event. The volume of racers also will dictate the number of medical staff and the amount of supplies required to safely conduct the event. Organizers should estimate when the largest group of runners (surge volume) will be in critical areas of the course and at the finish line to adequately staff the areas to control the spectators and provide medical care for injured runners. Large volumes of runners and mass crowds magnify the need for a chain of command that is understood by all staff to properly execute emergency protocols.
Fitness levels of participants
Each race is characterized by the number of participants and the range of fitness levels of its participants. The type of athletes participating in the event will influence the medical outcomes and organizational needs of the race. An exclusively elite competition will need a different allocation of resources than an event that requires previous performance qualifications to participate or a race with a mixture of all competitor levels. All races should be prepared for cardiac arrests, and events with a mixture of competitors with varying fitness levels will likely have more running injuries and overexertional outcomes that must be factored into the medical plan. Defibrillators and ACLS trained teams should be readily available for any potential cardiac events at all races. For races with high potential drop-out rates along the course, there should be a sweep system to transport racers to the finish line or meeting areas.
Volunteer Preparation and Education
A large task for the marathon organization is recruiting and organizing volunteers. It is almost impossible to host a large marathon race without the goodwill of volunteers, and it is vital to recruit qualified volunteer staff. The volunteers need appropriate education for the jobs they will be assigned on race day. It is beneficial to have a diverse group of medical volunteers including medical doctors, physician assistants, nurses (especially critical care and emergency department), nurse practitioners, physical therapists, athletic trainers, paramedics, and EMT. Podiatrists and massage therapists can be useful adjuncts to the medical team. Medical volunteers may be recruited from local hospitals and various organizations like the American Red Cross, the Medical Reserve Corps, the EMS community, the athletic trainer communities, amateur radio clubs, and from former volunteer staff.
The volunteer medical staff is often split into subsections or divisions. The leadership team includes the medical directors, communications leaders, and subsection or division leaders of the medical staff. The medical staff is often divided by professional backgrounds (MD/DO, RN, EMT, PT, DPM, PA, ATC, and so on), EMS coordinators, medical record leaders, medical security leaders, leaders in charge of the start and finish line areas, medical course tent organizational leaders, and family relations leaders. The division heads should meet starting several months before the race and integrate into the race structure. Local EMS groups in local hospitals and area emergency departments should be informed of the race plans for medical emergencies and be involved in the race planning when appropriate.
Medical volunteer staff education is a critical part of preparation. Medical protocols should be reviewed at larger medical volunteer meetings and videos should be provided for those who are unable to attend. The education is usually delivered with a combination of videos, medical meetings, written materials, and web site information. The education should include recognition and treatment of common race injuries, medical problems unique to endurance events, and medical emergencies along with the treatment protocols and emergency response protocols that are used by the race. High-yield topics include exertional heat illness, exercise-associated collapse, exercise-associated hyponatremia, and sudden cardiac arrest in runners. Regional emergency departments should be educated to recognize and treat hyperthermia (EHS) and exercise-associated hyponatremia in a timely manner. Medical providers should be briefed on the expected medical supplies and equipment that will be available for use and made aware of the limitations of the available equipment so that patients may be transferred to a higher level of care when their illnesses fall beyond the medical tent capabilities.
Planning for medical volunteer placement, allocating medical equipment, and delivering supplies to the proper area also are essential. Anticipating the surge capacity of each medical site as racers pass through different sections of the course optimizes the care of runners in predetermined areas of increased course difficulty. Larger allocation of staff and equipment should be supplied to larger foot traffic areas, such as the finish line, loop intersections, and areas of anticipated increased course difficulty. The types of medical supplies needed for optimal care should be determined and ordered several months ahead of the race. Organizers should have a team in charge of medical supply logistics and distribution to appropriate medical treatment sites. There should be a communication and transport system in place to allow for relocation and delivery of supplies during the race to locations in need.
An emerging and vital topic of education for all race volunteers and medical staff is the understanding of “scene safety.” Though compassion comes naturally to race volunteers and medical providers rush to aid anyone in need, volunteers must always first assure that the sites they are servicing are secured and safe before attending to others. The race response protocol must be emphasized during the education and preparation of all volunteer staff. Race organizers have the responsibility to ensure the safety of their workers and volunteers, in addition to the safety of the racers and the public. Again, the terrible Boston Marathon bombings in 2013 reemphasized the importance of assuring scene safety. Many volunteers placed their lives and safety at risk rushing to the aid of injured runners and spectators before the area was secured and before a third bomb was discovered and removed from the site. It was only luck that the third bomb was faulty and did not detonate. The importance of scene safety and personal safety cannot be overemphasized and should be applied across all spectrums of threats from weather to illness and to terrorism. Staff and volunteers should be educated to recognize threats and to remove themselves from any situation that may put their own health and safety at risk.
Dividing the Course Coverage Locations
Medical tent placement recommendations include tents traditionally set at the finish line and at several locations throughout the course. Loop intersections where the course might circle around to intersect at one point are typically good areas to set up medical tents due to the higher number of runners moving past those points. Areas of harsher terrain and large hills should have medical providers available. Race organizers should identify areas on the course that narrow the racing area and concentrate runner traffic and potential regions of the course that limit emergency vehicle access. For these crowded and less accessible areas, there should be designated EMS access and egress points in cases of emergencies. There should be designated prearranged points to transport people who are intercepted along the course for care and designated medical tents or ambulances to transport those requiring specialty care.
Water, electrolyte water/juices, and basic medical supplies should be available in the comfort care medical stations. Major medical tents, typically those at the finish line and high medical encounter areas, should have IV capacity, heating and cooling capacity, ALS capabilities, and ambulances. Medical staff should know which locations have advanced care capability, so patients are transported to the appropriate locations. All medical tents should be supplied with an automated external defibrillator. There should be medical supply vehicles available to replenish supplies at the medical stations. EMS should be readily available with ambulances stationed at set locations along the course or moving along the course, and at the finish line. A system should be established to transport runners who drop out of the race to preset common meeting areas. There should be set diversion locations to transport runners and the public as part of the incident command system should there be any threat to public and race safety (bombing, fire, vehicle accident). Mobile hazmat and reserve ambulances may be considered for any large race with potential mass casualty incident or threat that requires those services.
Multiple lines of communication are recommended for management during a race. There should be a common medical command center in place organizing communication between sites and divisions. It is helpful to use more than one communication system including a combination of handheld radios and cell phones. A common communication system, including at least one that is not reliant on the national cell phone tower grid, should be used between the race organizers and the division leaders, such as handheld radios. An emergency text message system that can be sent from a single source is valuable for transmitting information to all staff and volunteers. There are many reasons and causes for failed communication lines, most commonly overwhelming the cell phone capacity due to large volume use during the event. In instances of public safety concern, police or federal officials may prohibit certain radio or cell phone use. Race organizers should be prepared with multiple modes of communication should one or several systems be taken out of service for any reason. Clear communication pathways should be set up between course medical tents, sweep buses, finish line areas, and EMS. The communication infrastructure should follow the incident command structure.
Education for injury reduction should be provided to all medical volunteers and event participants. Education for volunteer staff may be provided in informational sessions and videos to recognize potential injuries and medical complications of race participation. Injury prevention information is most effectively distributed to participants online through the race organization’s web site, targeted emails, and social media. This should include information early in the training as well as emails in the days leading up to the event discussing weather conditions and health recommendations. Some high yield topics include proper training methods, common race injuries, preparing for hot and cold race conditions, hydration strategies, and strategies to avoid hyponatremia due to fluid overload. Runners should be made aware of red flag symptoms that may cause problems during endurance events. For instance, fever and viral respiratory tract infection in the week leading up to the event are associated with EHS and reasons not to start the race. Runners should be made aware of the cardiovascular risks of running and associated risk factors for sudden cardiac arrest during these events. Finally, runners should be aware of the impact of weather conditions on race safety and any race day flag systems or warning systems in use to inform participants of event modifications, cancellation, or emergencies.
Mental Health Support
Finally, it is important to recognize the importance of providing mental health support for racers, volunteers, and staff for a traumatic event affecting an individual (race related death) or a large-scale catastrophe (bombing with or without casualties). The race organization should be prepared to identify those in need of mental health support and be able to provide care to those in need. This may require coordination with the public and private sectors to provide mental health support to large groups of volunteers.
Marathon and other road races are popular events in the United States with record participation that inspire people to pursue physical activity and are an opportunity for personal growth and accomplishment. However, the wide attention and large participation may make some events targets for terrorist attacks with the risk of mass casualties beyond the usual medical encounter level of the event. Race organizers should establish a chain of command modeled on the NIMS and the Incident Command System to improve event safety and help communities practice for mass casualty events. Organizers should address local risk factors, educate and allocate volunteers appropriately, and divide the course and medical resources in a well-organized manner with open communication lines. There are additional resources for those interested in race medicine and more information that can be obtained through local race organizations and the International Institute for Race Medicine (22).
The authors declare no conflict of interest and do not have any financial disclosures.