The sport of triathlon, which combines swimming, cycling, and running, has been rapidly growing in popularity around the world. USA Triathlon (USAT) membership has more than tripled in the last 15 yr, and there are more than 4300 sanctioned competitions each year (23), with new events appearing each year. Triathlons vary in distance from sprint (shorter than Olympic distance), Olympic distance (1.5K swim, 40K bike, 10K run), half iron distance (2K swim, 56-mile bike, 13.1-mile run), iron distance (2.4-mile swim, 112-mile bike, 26.2-mile run), and ultradistance triathlons, which are longer than the traditional iron distance.
Increase in race distance has been shown to correlate with increased medical utilization (7,10,13,16,19). Reported medical utilization rates for shorter race distances have been reported as 17 to 50 encounters per 1000 race starters (7,10,13), while longer distance races have medical utilization rates as high as 100 to 375 per 1000 race starters, respectively (10,14,16), depending on climate and fitness level of participants (17).
The majority of medical evaluations occur at the finish line with the most common presenting symptoms of gastrointestinal issues, fatigue, and/or dehydration (5,7,10). Despite a low incidence of medical evaluations during the swim leg, the majority of catastrophic deaths during triathlon occur during the swim leg (24). Death rates during the swim leg of triathlon are almost double that of those previously reported at marathons (8,15). While the majority of medical issues cared for at triathlons are relatively benign in nature, it is important that medical directors understand the potential for catastrophic injury and are prepared for race day emergencies.
The goal of this article is to provide race directors (RD) and medical directors with a framework for planning and organizing medical coverage during a triathlon to maximize participant safety.
Prerace (Course and Event Planning)
Proper planning and prerace coordination of the medical plan can have a profound impact on the safety and enjoyment of the race by athletes, volunteers, family members, and spectators. Ideally, the medical director should meet with the RD and other local entities in the initial planning stages to have the opportunity to review course and finish line layout. When evaluating the racecourse, the medical director must consider aspects of medical logistics such as athlete access and egress from the different portions of the race. This includes accessibility of the medical tent for athletes after the race and the ability of ambulances to access and leave the finish line medical tent without obstructing racers that are still on the course.
The medical director also should work with local emergency medical services (EMS) and local hospital emergency departments to plan for any additional EMS staffing or repositioning of EMS response units that may potentially impact local EMS and hospital services. Hospitals that have been identified as the main medical transport center for ill or injured athletes also should plan for additional staff dependent on the number of race participants and potential number of hospital transports.
The medical director should be responsible for outlining the race day medical requirements, logistics and medical treatment protocols in an event medical plan. The medical plan should consider how the medical team responds to medical emergencies not only in the medical tent, but also before and during the race for injured or ill athletes or spectators (12). Races of different sizes and distances as well as differing local weather and course conditions will significantly impact medical planning.
Medical conditions seen and treated in race medical tents include common injuries and illnesses (Table 1) that medical providers may be familiar with but also can include medical emergencies that may differ from what medical providers see and treat on a daily basis in their typical medical practices. To best prepare volunteers for medical emergencies, having clear emergency treatment protocols of specific race day medical conditions, such as exertional/exercise-associated collapse, hyponatremia, hyperthermia, and cardiac arrest, can help ensure the best possible outcome for an ill athlete (https://www.usuhs.edu/sites/default/files/media/mem/pdf/mcmalgorithms2011.pdf). Several major races distribute these protocols to medical volunteers via a mobile device application, available for review ahead of the event or for use during the race. Further, the medical director should have knowledge of the race day contingency plan and use this information in the design and planning of the event medical support structure (25).
Disaster and Mass Casualty Planning
Because sporting events can be considered a “soft” target for terrorist attacks as evidenced by the 2013 Boston Marathon bombings, the medical director also should consider the need for a Mass Casualty/Disaster (MCD) Plan as part of the written medical plan (2). This MCD plan should be developed in collaboration with the RD, local EMS, hospital systems, and key volunteers. In the event of a mass casualty event, the medical plan should determine how the race day medical team would coordinate rescue efforts with local EMS, law enforcement, and the on-scene incident commander (4).
Medical Legal Issues
Mass participation events in the United States and abroad are not immune from potential legal concerns (18). Medical directors (as well as individual providers) should confirm the level and extent of malpractice insurance provided by the race organizers. “Good Samaritan” laws are not designed to provide protection for volunteer athletic events because the legislation does not apply to nonemergent care. A physician’s personal liability or institutional policy may provide coverage for volunteer athletic events, especially if the employing medical entity is the medical sponsor of the event, and the event is therefore viewed as part of the physician’s usual employment. However, providers may desire to consult with their usual malpractice provider to determine how much coverage if any is provided.
If the provider’s individual liability policy does not cover volunteer coverage, a separate medical insurance policy may be obtained — individual providers or event directors can apply for a temporary USAT event coverage insurance, which is low cost indemnity coverage at a cost of US $50 to US $60 per licensed medical provider (http://www.usatriathlon.org/audience/race-directors/insurance.aspx). Finally, most insurers will only cover providers if they are acting competently and practicing within the limits of their training and experience. Because triathlon may expose the provider to conditions or situations not specifically covered in their usual practice, it is imperative that treatment protocols are provided for care and that medical volunteers are familiar with these protocols.
Events Out of State
Occasionally, the volunteer physician will not be licensed in the state in which the event occurs. Physicians must be aware of the state laws that affect the practice of medicine in that state. Not all states allow the provision of volunteer medical service under the Good Samaritan legislation for visiting physicians. Currently, Colorado, Washington, Florida, Utah, Louisiana, and Montana offer a “courtesy license,” which will provide some protection; however, this is not available in all states. It may be advisable to check with the medical board of the state you will be volunteering in. Of the state medical boards that do not allow out-of-state physicians to practice in their state, none reported actually taking legal action versus out-of-state physicians (6).
Organization of the Medical Team
An event medical director must be named by the organizing RD and should be a medical physician (MD or DO) with experience caring for both the medical and musculoskeletal needs of endurance athletes as well as cardiopulmonary and medical emergencies that may occur on the course or in the medical tent. While the medical training of physicians make them most qualified to serve as medical directors, smaller triathlons may not be able to obtain physician coverage. These races should consider using a licensed health care provider with an understanding of the medical concerns of triathlon or endurance sports. The event medical director will have oversight over the medical care and may modify these guidelines based on the weather, course, and specific race historic medical utilization. Roles of the event medical director include:
- 1) Communicating with the organizing RD including regarding course safety;
- 2) Development of medical treatment protocols;
- 3) Recruiting and training of a medical team, both at the finish and on the course;
- 4) Organization of the medical facilities, tents, aid stations and respective supplies;
- 5) Organization of documentation protocols for athletes receiving medical care; and
- 6) Communicating and coordination with EMS and local hospitals.
It is recommended there be one physician for every 200 competitors, with a recommended minimum of at least two physicians for any event — one physician stationed in the medical tent, while the other can be mobile to respond to needs on the course (11,21). All physicians must hold an unrestricted medical license and should have training in basic cardiopulmonary and medical emergencies. Physicians must be granted the authority to remove any competitor from the event for safety or health concerns (11).
Medical Tent Staff
There should be one medical staff member allotted for every 100 competitors (11,21). All medical staff should have training in caring for acute injuries and medical calamities. It is ideal to have providers with varying skill sets including nurses, EMT, paramedics, ATC, MD/DO, residents/fellows, and physical therapists (if trained in event coverage). The training and credentials of nurses equips them with the skills required to work in medical tents that offer laboratory services, dispense medications, provide intravenous (IV) fluids, and monitor medical illnesses on-site. Therefore, medical directors are encouraged to enlist nurse volunteers as key members of their tent team.
There should be one finish line spotter for every 200 to 400 competitors (11,21). Finish line spotters must have training to identify athletes that require medical evaluations and must be able to transport these athletes to the medical tent. The number of on course medical spotters will vary based on course design (point to point versus multiple loop), but an initial estimate should be one on course spotter for every 300 competitors (11,21). These personnel may include aid station personnel, police, EMT, paramedics, and mobile medical staff. The medical director also should coordinate staffing needs with the local EMS and emergency departments to ensure availability and proximity, based on the number of event participants.
Ancillary services (chiropractors, massage therapists, podiatry)
While on-site massage therapy, chiropractic care, and podiatry are often provided at multisport events, they are not mandatory and if provided, these services should not be provided in the medical tent to minimize congestion. Because these specialties may not have training in cardiopulmonary and medical emergencies, they should not serve as treating medical staff but may serve as on course and finish line spotters. On-site ancillary providers should have training to recognize athletes that require medical evaluations and must refer these patients to the medical staff immediately.
Layout and Flow of the Medical Tent
The medical tent should be “down line” from the finish (Fig. 1) with a degree of physical separation that allows athletes to complete the event, cool down while being observed by medical spotters or allow self-determination of medical needs. However, it should be close enough and in a direct route of traffic flow so that transport (self, urgent, or emergent) to medical is possible. The medical tent should not be in the direct path of the finishing line to minimize unnecessary traffic of noninjured athletes through the medical tent. Further, the location of the tent is important if emergent transport of athletes is required. It is important that EMS must not cross or impede the event or interfere with postrace flow whenever possible. If possible, locating the finishing tent near the nutrition tent would be desirable as well.
Medical tent size and structure
The medical tent should be in an accessible, well-identified, protected, ventilated, secured area/structure which is adequate in size and functionality to accommodate the peak volume of athletes requiring care for a given event. The care volume is a function of expected absolute numbers and predictions of general finish times for the largest volume of competitors. While most Olympic distance events will see approximately 1% of participants requiring care (10) and the most recent International Triathlon Union guidelines predicted up to 4% at the elite level (11), extreme conditions may result in as high as 17% (14). Even for the same distance, the competitor “training profile” will vary and impact care needs, volumes, and timing of presentation (7).
Flow and traffic pattern
In simplest terms, care flow requires the following progression — triage, intake/registration, assignment of care area, care provided with resolution of symptoms and discharge or failure of symptoms to resolve and emergent transport. The event size and duration will, for the most part, dictate how distinct each of these services may need to be (Fig. 2).
For shorter distance or smaller events, the care team may have overlapping roles and the “flow” is short. Triage may be by the treating staff. Intake and record keeping may be one and the same. Entry to medical area may be the same as exit. Even in this model, how and where an athlete is assessed, enters the system and exits must be clearly defined. Unrestricted or undefined access compromises the ability to assess and determine the severity of medical issues and provide care. The flow of care must be defined as much by care protocols as by where care is provided. Finally, a defined “discharge portal” must be present — to assure completion of care and to “move people along.”
As event size and anticipated services grow, a more defined structure of the care area must be present. Care should be taken to restrict access to the press, other spectators, or any nonessential personnel as to minimize disruption to care or breach of patient confidentiality. As triage serves to gatekeeper entry to the medical area and define acuity of care, it must be the first phase of medical services and precede the tent proper. Immediately following should be intake/registration (see section on medical record keeping) and determination wherein the tent services are provided. This flow pattern is critical to ensure accurate initial information at the onset of care to control volumes in areas of the tent and to have an accurate record of who is requiring or has completed care. Based on event size, all care may be in the same area or may require the establishment of specified areas for self-care (i.e., no medical provider intervention required), observation area (assessment and medical oversight but not active intervention), and medical intervention/care area. Within the medical area, there must be clearly designated and readily accessible space for general supplies, emergency medications, and automated external defibrillators (AED). Finally, consistent exit from care must be established. For recovered athletes, this should pass the intake area to allow discharge recording — this minimizes staff requirements, ensure recording of in/out, and allows oversight of volume distributions within the medical service area. For the occasions of continued care off site (emergency transport), the EMS portal must be such that it allows the most efficient access to the acute treatment area to support expedited next level of care and exit from the med area and race site.
Equipment and Supplies
Medical supplies will vary from race to race depending on length of race, number of participants, budget as well as relationship with local medical facilities (Table 2). Medical tents should include, at a minimum, basic equipment to obtain vital signs and perform a basic medical examination including blood pressure cuff, thermometer, stethoscope, and portable pulse oximeter. All races should have provisions to address life-threatening events. Smaller races may rely on local EMS availability at finish line, while larger races may (and should) stock their medical tent with basic life support supplies and equipment. All medical tents should consider having an AED. Many larger endurance events, particularly marathons, have AED on the course either in fixed locations or on the back of bicycles or other vehicles. The determination to stock and dispense medications should be made before the race and should be advertised to the participants.
Those races that elect to stock medication or treatment for life-threatening events should have supplies to treat acute allergic reaction, cardiac events, asthma, hypo/hyperthermia, hyponatremia, and hypoglycemia. These should include epinephrine, inhaled beta agonists, antihistamines, aspirin, and at least one AED. All races should have a means of cooling racers with hyperthermia. Evidence supports the use of cool water immersion (3); therefore, a large tub (or children’s sized pool) is recommended for immersion. For those races where hypothermia is possible, having blankets and hot liquids is advisable. For longer races with risk for athletes developing hyponatremia, pre-event weights and using the same or equivalent scale to weigh participants upon entrance to the tent is encouraged. Urine test strips are helpful in the diagnosis and management of potential rhabdomyolysis. Test strips positive for blood in the urine may represent myoglobinuria, which would necessitate aggressive hydration and urgent transport to the nearest hospital. Finally, a glucometer, glucose strips, and a rapid glucose replacement source are advisable.
Beds, cots, lawn chairs (adjustable chaise lounge style), and/or folding chairs are necessary to support and stage the athletes. For treatment of exercise-associated collapse, having blocks or other means to place the athlete on the cot/bed into legs up, head down (Trendelenburg) position are valuable (1).
Medical tents should stock or have access to oral fluid replacement including water, electrolyte drinks, and for colder conditions warm soup or broth. Many long distance races stock IV fluids, fluids (normal saline), and appropriate IV access supplies and means to secure fluid bags, such as IV poles or zip ties to secure to medial tent. Administration of 3% sodium chloride is the initial treatment of choice for symptomatic or severe exertional hyponatremia and should be stocked if plans include hyponatremia treatment on-site (9).
It is advisable to have point of care laboratory capabilities such as the i-STAT Portable Handheld (Abbot Systems, Abbot Park, IL) able to measure sodium, potassium, glucose, and hematocrit, for long course triathlons or those conducted in extreme weather conditions. It is recommended that in cases where exertional hyponatremia is suspected that a serum sodium level be obtained before IV fluids are started (9,20). Additionally, those athletes with altered mental status, significant gastrointestinal distress, or large muscle group cramping should have blood collected for analysis at time of initiation of IV fluids.
Abrasions, “road rash,” lacerations and blisters are a common injuries sustained during the bike and run legs of triathlons. Supplies to treat abrasions and road rash include anesthetic agent, such as lidocaine, latex and nonlatex gloves, soft scrub brush, a water source, topical antibiotic ointment, and sterile dressings. Equipment to suture minor lacerations (and/or cyanoacrylic skin adhesive) is valuable if it falls into the medical tent's budget. The medical director should consider having disposable suture kits, sterile gloves, syringes, needles, and an anesthetic agent, appropriate suture material, and supplies to irrigate and dress the wounds similar to abrasions. Bandages, sterile dressings, antibiotic ointment should be available for small abrasions and blisters.
There are many miscellaneous supplies to consider to include sharps containers, garbage bags, biohazard bags, hand sanitizer solution, plastic bags for ice, sunscreen, sheets or table paper, cleaning supplies to clean bed in between patients, pens, clipboards, medical record sheets, writing utensils, paper for patient discharge instructions, and wheelchairs to transport racers from finish line to medical tent.
If an athlete receives medical care or aid in the medical tent, such as IV fluids, oxygen or medications, termination or disqualification from the race should be considered because they may possess an unfair advantage over other competitors or the early manifestations of a more serious medical concern.
Medical Record Keeping/Documentation
Real-time recording of assessment and medical intervention is necessary for the care of the athlete. In the event of a transfer to another facility, accurate representation of the care that has been provided will aid the receiving treatment facility. Finally, medical tent records can be used for “quality management,” as well as for planning for subsequent event needs. All the components of preintervention history, documentation of provisional diagnosis, care plan, intervention and outcome of care, and disposition status should be succinctly documented.
Ideally, as part of event registration, athletes should include their pertinent medical history and allergies at the time of registration As an alternative, while not permitting pre-event adjustment of services or flagging of “at risk” athletes, race numbers can include (on the reverse side) an optional short medical history form, which when competed can provide a very effective means of initiating care and avoiding missteps in care (Fig. 3). Unfortunately, this form is often not completed. An option to improve information capture is to request completion at time of packet pick up and link packet or t-shirt pickup to the completed form.
Recording of care
The format for medical documentation should be concise, simple, no more than one page, and legible. The authors have created the “Universal Triathlon Medical Record” which has been formatted to allow recognition of care triggers, “direction” of care and ensure required information is documented (Fig. 4). Not only must all care be documented, records must be maintained (securely) per HIPPA compliant and local standards because the care provided may later require review (for insurance or legal purposes).
On race day, the medical director's role should be one of supervision and delegation of the medical team in meeting the medical needs of the athletes and ideally should not be involved in direct patient care. The medical director should have well-documented delineation of duties and expectations for each medical volunteer position and how these positions should collaborate on race day. Communication between members of the medical team should follow a clear chain-of-command from volunteers to the medical director to RD and with appropriate emergency personnel. A well-trained group of medical volunteers that can adequately communicate and understand and respect the skills and capabilities of each member will help insure a safe and less stressful working environment.
On-site drug testing of athletes may be required at certain events and is an important part of maintaining a safe and level playing field for all athletes. While drug testing/anti-doping control will likely occur at many high-profile professional events, it is less frequent at the majority of smaller domestic races. If drug testing is to occur, domestic national governing body (NGB) staff should coordinate the logistics with the RD. If a domestic RD wants to request on-site testing for their event, they can do so by contacting USADA directly and setting up a program on a contract basis (22).
The medical director is just one member of a larger team of individuals who is responsible for safety planning for the swim segment. This group typically includes the RD, safety director, swim course director, lifeguards, local EMS, personnel and perhaps representatives of the race venue itself. Safety personnel (lifeguards, kayakers, surf/paddle boarders) should be stationed on the course both to identify swimmers in distress and provide rescue, if needed. There should be one swim safety staff on the course for every 25 to 50 swimmers, depending on the distance and environmental conditions and at least one medical staff at the swim exit (5). Finally, an AED should be accessible at the swim venue both at the exit and on the swim course.
For race day safety, three components must be considered. Will the anticipated water temperatures fall within safe participation parameters (with or without wetsuit use); is the water quality of the venue acceptable; does the swim course layout allow rapid and safe assessment, on course care, and evacuation (from water and from the venue) of a compromised athlete if needed. The medical director should have substantial input into the decisions regarding the safety of the swim segment. The policy and person responsible for making swim segment cancellations should be clearly defined before the race (26).
The USAT swim collar task force has determined temperature parameters for the swim safety — with and without wet suit use (28). These define participation risk based on distance; water temperature and wetsuit use. Whenever possible, use of historical data on water temperature for the event date should be used in determination of the swim site and distance during the planning phase. The risk table not only allows estimation of participant hypo/hyper thermic risk but also provides support for alteration of an event swim distance (or cancellation) based on race day temperatures.
The water quality of the swim portion is important to minimize swimming-related infections to athletes. The water at the venue should meet local or state water quality standards for swimming. Local and seasonal trends for environmental conditions should be considered as part of venue and swim course planning (https://www.usms.org/admin/lmschb/owgto_safety.pdf). International Triathlon Union events require submission of water quality test results 15, 12, 2 months, and again 7 d before competition to ensure water quality safety (11). Medical and RD are encouraged to work with their local environmental protection agency to ensure that water quality is safe for competition.
Given that the highest number of event related mortalities occur during the swim, how a swimmer — or victim — with a life-threatening medical emergency can be quickly identified, rescued and delivered to shore, and receive advanced medical care is of ultimate concern. Coordinated planning between the medical director, swim safety team, and on-site EMS is required to ensure that there is rapid access to an athlete in distress, athlete retrieval, and the ability for rapid egress of emergency vehicles.
Medical input into the bike and run have similar considerations — using medical decision making when considering the need for access and emergent egress while trying to minimize disruption to the race. Race resources may dictate whether the bike/run course is open or closed to traffic or if it is a point-to-point or a multiple loop course. Course configuration also is an important consideration when determining the use and placement of medical resources. A multiple loop course will allow for more consistent availability of medical resources on the course. The ability to minimize distance travelled by medical resources to points on the course can be addressed in the course design process and with an awareness of the impact of the event of road closures and traffic flow. When possible, EMS access should not go against the flow of the race, should cross the race for access as seldom as possible, must allow for rapid transport from the course, must be planned with alternative means of access and egress from the race route and do all of this with minimal disruption of the competitive component of the event.
The RD and/or medical director should follow up on any athletes transported from the medical tent or race course to local hospitals to determine their final disposition while following existing patient privacy laws. The medical director should meet with the medical volunteers/staff to debrief and submit an after action report (AAR) to the RD/organizer detailing how well the medical plan served the race and athletes with suggestion on how to improve the medical plan for subsequent events.
Triathlon is a popular and typically safe sport for competitors. The medical director shares responsibility with the RD for event and athlete safety. Safe participation can be maximized with a preplanned, rehearsed, and well-communicated race medical plan. These guidelines aim to increase the medical director’s knowledge of proper supply and staffing, preparation for common triathlon medical conditions, impact of course design, and the administrative tasks of the medical director. A well-prepared medical director and medical staff will ensure that safety is optimized, and the competition is safe for all participants.