10/3/2016 Introduction • Last 25 years tremendous growth in multisport adventure races Adventure Race Medicine • Advanced and improved Healthcare that Works 2016 outdoor equipment • Trevor Turner MD, FAWM More efficient and affordable travel Brief History Events Included • Eco-Challenge started in the U.S. in 1995 • Caving • Fixed-line mountaineering • Flat and white-water boating • Primal Quest (1 st expedition length race • Hiking exclusively in USA) in 2002 in Telluride, • Mountain biking CO began major network TV coverage • Navigation and orienteering • Technical climbing and rope skills • Trail running • Governing body formed in 1998 is now USARA • Trekking United States Adventure Race Association Unique Attributes Rules of Travel • No set course between checkpoints and • Dictate aspects e.g. where and when team can transition areas travel on paved roads, use trails, get water • ALSO govern use of medications, specify penalties for use of medical resources during • Each team given map with UTM (Universal the race, outline criteria for withdrawal from Transverse Mercator) coordinates the event • Breach of these rules penalties • No built in rest strategy based on a team ranging from extra time to strength and weakness disqualification 1 10/3/2016 Goals of Care 9 Elements of Planning • Rapid access and triage • Crowd size • Transportation • Personnel • Medical Records • Stabilization and transport of seriously ill or injured • Medical Triage & • Public information Facilities • On-site care for minor injury or illness • Mutual Aid • Communication • Data Collection Medical Support Categories Examples in Category 4 I. Spectators seated for duration of event • Rough and remote terrain – stadium events, concerts II. Spectators are mobile/may become participants • Logistical difficulties with communication – Golf tournament, Mardis Gras III. Large geographic area where participants • outnumber spectators Prolonged transport time to definitive care – Marathon, triathlon, cycling IV. 3 + extreme events and unique challenges • Requirement for technical search – Adventure racing and related endurance events and rescue Mass Gathering Recommendations Controversies • Basic first aid in 4 minutes • Penalties for acceptance of medical support 1) 4 hour penalty to accept IVF • ALS care in 8 minutes 2) Require >2L IVF or multiple IVF = disqualification 3) All who require IVF must be medically cleared by • Evacuation to medical facility in 30 minutes race director prior to return to play • Minimum 2 person team (RN, EMT, paramedic) • Conflicts when medical team and per 10,000 participants athletes disagree about RTP – Rates of utilization ~ 0.5-2 patients/1000 athletes 2 10/3/2016 EMS & SAR Medicolegal Aspects • Expedition length races cover multiple • Liability of volunteer vs paid responder? hospital, trauma center, EMS/SAR jurisdictions • Licensed personnel require insurance beyond general liability policy per event • Integrate member of the local EMS • Validity of liability waivers community as liaison b/t race and local • What constitutes practice of medicine? medical community • Controlled substances in medical kits? Injury Patterns in 223 Surveyed Injuries and Illness Primal Quest Adventure Racers Class Acute v. Chronic Type N = 302 Percentage • Advanced 44% 59% • Skin/soft tissue • 145 48% • Respiratory • 55 18.2% • • • Intermediate 35% 54% Altitude (AMS/HAPE) 36 11.9% • Orthopedic • 29 9.6% • Dehydration • 21 7% • Beginner 19% 56% • Gastrointestinal • 6 2% • HEENT • 5 1.7% • Genitourinary • 3 1% • Other • 2 <1% Trends Acute Mountain Sickness • Acute injuries in adventure races > triathlons • Incidence and severity depends on rate of • Most common site of injury ankle>arm and ascent and altitude obtained, duration of shoulder>knee>low back exposure, level of exertion, inherent physiologic susceptibility • While injury is more common, illness more medical withdrawals from event • Headache, fatigue, dizziness, anorexia • Reactive airway disease/asthma incidence • Specific physical findings often lacking high (N.B. progressive decline in both FEV 1 & • NO NEURO FINDINGS unlike in High Altitude FVC from baseline up to 20%) Cerebral Edema 3 10/3/2016 High Altitude Pulmonary Edema Endemic Disease • Most common cause of death • 1997 Raid Gauloises in South Africa 13 cases related to high altitude African tick-bite fever Rickettsia africae • Prevalence depends on rate of ascent, altitude reached, degree of cold, physical exertion, and • 2000 Eco-Challenge Borneo 80 cases individual susceptibility Leptopspirosis (immersion Segama River) • Fatigue, weakness, dyspnea on exertion, • persistent dry cough, nail beds cyanotic 2001 Para Jungle Brazil myiasis screwworm fly larvae Cochlomyia • Pulmonary edema may manifest w/ neuro sx hominivorax Dehydration and Hyponatremia • Serum sodium <135 1) 0.5L fluid in per Lb. with malaise, lost disorientation, 2) 1g/hr Na replacement hyperreflexia, nausea, in races >4h fatigue 3) 1 week to acclimatize • Mechanism? Net H 2O from cooler climate + gain and Na lost vs. Na 10-25g/d Na depletion 2/2 massive 4) IVF therapy races >4h sweat losses 5% dextrose in normal saline 4.