Burden of Injury and Illness in the Road Race Medical Tent
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General Review Burden of Injury and Illness in the Road Race Medical Tent: A Narrative Review 02/08/2020 on H7mGCzFrxnTiEfG/GVUfSHU3QL7euWXEeSLNkJmtHtx6pYGjzLYMmam1vf7zd3jlyy8O10N/beblDEP3NQ6l/TKeo5kvsxXltnOX2diaB69isRHO214Eml3yz4T3k0nvsDvUhwdziP6vxvddTwX6cE5CL2kPKFx1 by https://journals.lww.com/cjsportsmed from Downloaded Rebecca G. Breslow, MD,*†‡ Carew C. Giberson-Chen, BA,† and William O. Roberts, MD§‡ Downloaded from Abstract https://journals.lww.com/cjsportsmed Objective: To summarize the literature relating to prehospital care at 5 km through marathon distance road races and present the epidemiology of common medical encounters, significant medical complications, and medical outcomes. Data Sources: We searched PubMed and Google Scholar for the published literature pertaining to road race medical tent encounters at 5 km through marathon distance road races from 2000 to 2018. We included English-language, original articles reporting on injury and illness incidence. Main Results: Standard medical encounter definitions have recently been formulated in response to the previous lack of uniform definitions. The incidence of medical complications at road races may be influenced by environmental conditions and by H7mGCzFrxnTiEfG/GVUfSHU3QL7euWXEeSLNkJmtHtx6pYGjzLYMmam1vf7zd3jlyy8O10N/beblDEP3NQ6l/TKeo5kvsxXltnOX2diaB69isRHO214Eml3yz4T3k0nvsDvUhwdziP6vxvddTwX6cE5CL2kPKFx1 race distance. Minor and moderate medical encounters, such as dermatologic injuries, musculoskeletal injuries, and exercise- associated collapse, are common. Serious and life-threatening medical complications, including exertional heat stroke, exercise- associated hyponatremia, and cardiac arrest, are less frequent. Fatalities are also rare, with rates of 0.3 to 5 per 100 000 participants reported at marathons. The ratio of hospital transports to medical encounters is low. Conclusions: On-site medical services play a key role in the safety of both runners and the community. Future research and care initiatives in this field should focus on optimizing treatment protocols, promoting injury prevention efforts and reducing host community costs. Keywords: distance running, road races, prehospital care, medical encounters (Clin J Sport Med 2020;00:1–7) INTRODUCTION the timing of its publication was a sensitive issue. The implications, that marathons disrupt community infrastruc- In the current review, we summarize the literature relating to ture and have the potential to adversely affect those in the prehospital care at 5 km through marathon distance road community not participating in these events, could be races. We present the epidemiology of common medical construed as critical of large-scale urban marathons. How- encounters, significant medical complications, and medical ever, the study actually provides strong evidence that every outcomes. By describing common and serious medical effort should be made to meet the medical needs of road race encounters, as well as what is known about injury and illness participants on site so as not to drain resources and negatively rates, we highlight the key role of on-site medical services in impact the host community. the safety of runners and the community, in addition to In 1975, the American College of Sports Medicine maintaining the feasibility of these events. recognized the need to mitigate health risks at road races, focusing on detection and management of heat-related illness BACKGROUND in a position statement.2 Key recommendations were to cancel races if wet bulb globe temperatures exceed 28 degrees Celsius During the week of the 2017 Boston Marathon, a report by (°C) to provide frequent fluid stops along a race course and to Jena et al1 was published in The New England Journal of formulate a medical care plan to treat runners with exertional Medicine concluding that Medicare beneficiaries who suffered heat stroke. Subsequent reports such as those by England on acute myocardial infarction in marathon-affected cities on the 1979 Peachtree Road Race,3 Richards and Richards on the marathon dates had delayed transport times and higher 30- 1978 to 1984 City-to-Surf fun runs in Australia,4 and day mortality rates than those admitted on nonmarathon Sainsbury on the Great North Run in England5 provided dates. Boston, along with 10 other large urban centers, was further information on medical support procedures and injury one of the marathon-affected cities included in the study; thus, statistics. Publications on medical encounters at the Boston on Marathon,6 the Toronto Marathon,7 and Grandma’s Mara- 02/08/2020 Submitted for publication August 6, 2019; accepted January 19, 2020. thon8 then showed that longer endurance events posed the From the *Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; †Harvard Medical School, Boston, Massachusetts; greatest risks. Following the 2000 publication by Roberts of §Department of Family Medicine and Community Health, University of Minnesota, 12 years of medical injury and illness data from the Twin 9 Minneapolis, Minnesota; and ‡International Institute for Race Medicine, Plymouth, Cities Marathon, an increasing number of epidemiological Massachusetts. studies on this subject have been published. The authors report no conflicts of interest. Corresponding Author: Rebecca G. Breslow, MD, Division of Sports Medicine, METHODS Department of Orthopaedic Surgery, Brigham and Women’s Hospital, 45 Francis St, Boston, MA 02115 ([email protected]). We reviewed the published literature pertaining to road race Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. medical tent encounters at 5 km through marathon distance http://dx.doi.org/10.1097/JSM.0000000000000829 road races from 2000 to 2018. We identified pertinent articles Volume 00· Number 00· Month 2020 www.cjsportmed.com 1 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. R.G. Breslow et al. (2020) Clin J Sport Med from PubMed and Google Scholar using the search terms adult finishers required medical tent care.13 This study also medical tent, road race, marathon, exercise-associated col- included an analysis of medical encounter data for youth lapse, exertional heat stroke, exercise-associated hyponatre- runners (ie, those younger than 18 years) and found a much mia, and exercise-associated cardiac arrest. We identified lower medical encounter incidence of 13 per 1000 youth additional studies from the references of relevant papers and finishers. At another metropolitan marathon held in 2001, from the International Institute for Race Medicine medical which also included a 5-km race and a 4-person relay, Nguyen manual.10 Figure 1 illustrates our search strategy. To facilitate et al reported medical encounter rates of 228 per 10 000 (23 comparison of incidence rates between studies, in some per 1000) entrants,14 similar to the experience at the Baltimore instances, we converted incidence rates to per 100 000 or marathon between 2002 and 2005 (34 per 1000 entrants)15 per 10 000. We also rounded to whole integers and/or 2 and the 2006 London Marathon (18 per 1000 finishers).16 significant digits. Marathons held in warmer weather conditions have higher overall medical encounter rates. For example, at the 2000 RESULTS AND DISCUSSION Houston Marathon, where the starting relative humidity was 93% and the peak temperature was 25°C, 36 per 1000 Table 1 shows the final results of our search. entrants and 47 per 1000 finishers received care in the finish line medical care area.17 Hsieh et al18 reported a very high rate of medical encounters—181 per 1000 starters and 214 per Definitions 1000 finishers—at a marathon held on an exceptionally In response to the lack of uniform definitions of medical sunny, hot, and humid day (starting relative humidity 97%, encounters at large-scale endurance events, a consensus statement peak temperature of 30.6°C). By contrast, Lee et al19 reported on medical encounters at mass participation sporting events was on the 2006 Adidas Sundown Marathon in Eastern Singapore, recently published.11 In this document, “medical encounters” are held overnight to avoid the characteristic warm, humid defined as medical problems reported to the event medical team environmental conditions; only 0.18 per 1000 (18 per 100 and requiring assistance either during or up to 24 hours after the 000) starters and 0.21 per 1000 (21 per 100 000) finishers event. Medical encounters can be subdivided into minor, were treated in the medical tent. moderate, or serious/life threatening, with event-related sudden Half-marathon and shorter distance road races have lower cardiac arrest or sudden cardiac death or event-related sudden medical encounter rates than marathons. At the Two Oceans death, at the most severe end of the spectrum. Medical encounters Races in South Africa, which includes a half-marathon and can be further classified by diagnostic category, either illness- a 56-km ultramarathon, the medical encounter rate for the related (organ system) or injury-related (anatomic region), and half marathon from 2008 to 2011 was 5.1 per 1000 starters.20 coded according to the modified Orchard Sports Injury A subsequent study, which examined medical encounters at Classification System (OSICS 10.1).12 Two Oceans between 2012 and 2015 after a prerace medical screening and education intervention, reported a lower rate for the half-marathon race of 4.1 per 1000 starters.21 At the Incidence of Road Race Medical Encounters Indianapolis Half Marathon between