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In It for the Long Run

Chiampas1

“Runner down.”
These two words bring instant concern to the medical director of a marathon, as well as reflection on the preparation and planning leading up to and during an event. Although the majority of collapsed-athlete calls tend to be for benign conditions related to the normal physiology of the event and prolonged activity—such as dehydration and heat-related injuries, altered mental status and diabetes-related problems—your response system must be prepared for and anticipate the worst.

Best Practices
It’s estimated that six to eight marathon runners will die each year while competing in the U.S. due to the combination of occult disease and superimposed physical and/or environmental stresses.(1) In fact, in 2009, six runners died in the U.S. while participating in half-marathons. And marathon running has increased significantly over the past three decades, with more than 470,000 runners in 2008, up from 25,000 in 1976.(2)

Although regular exercise and increased cardiorespiratory fitness are associated with decreased cardiovascular mortality, there’s still concern that prolonged exercise can lead to morbidity, especially in less-than-ideal conditions. EMS and marathon medical teams must be well prepared for these events; one AED and one ECG monitor at the finish line isn't sufficient.

During the preparations for medical care at the Bank of America Chicago Marathon, the issue of cardiac death is always at the forefront. The event’s more than 45,000 runners and 1.2 million spectators necessitate a unified and coordinated effort among EMS and the medical staff. More than 1,200 medical personnel and EMS responders are in place to respond to these critical events.

Recently, we’ve collaborated with other large marathons, including the Boston Marathon, and their medical teams, to enhance our responses. The result: In addition to substantially increasing the number of AEDs on the marathon route with the medical teams, we also made sure that all teams are able to access and respond in a rapid and optimal manner to each collapsed runner. These marathon route teams include ALS bike teams, ALS golf cart teams and BLS/AED-equipped foot teams. Between these specialized response teams and the ALS ambulances for the event, the number of AEDs present on race day exceeds community standards for a 26.2-mile course. We have one AED at every aid station (21) in addition to the ALS/AED equipment on the ambulances and with the bike teams.

Finally, our main medical tents are equipped with 12 cardiac monitor/defibrillators that allow our teams to assess cardiac rhythms and core body temperatures, which is critical in providing exceptional care while still having the capability to respond to cardiac failure.

These measures have been adopted as best practices by several marathons around the world. In the U.S., the Houston and Twin Cities marathons follow our AED and cardiac monitor/defibrillator protocols.

In addition, the Medical Summit of the World Marathon Majors (Chicago, Boston, New York, London and Berlin marathons) in January 2010 identified the use and distribution of AEDs as outlined above as best practices for large-scale marathons. And at the 2010 American College of Sports Medicine conference, Bill Roberts, MD, highlighted the use of AEDs in his lecture, “Avoidance of Adverse Outcomes in Marathons.”

The bottom line: Medical directors of marathons realize sudden cardiac arrest can and will occur during competitions, and EMS and marathon medical teams must be prepared to respond as rapidly as possible to give those runners a chance for survival.

Monitor & AED Placement
In the past few years, there have been several instances where AEDs and cardiac monitor/defibrillators have played a key role in saving runners’ lives. During the 2009 Houston Marathon, medical staff using a cardiac monitor/defibrillator determined that a runner was having a heart attack. The runner was transported to the hospital and found to have a blocked artery, which was opened with a stent. And, during this year’s Houston Marathon, a bike medic used an AED to deliver a shock on a runner at mile 13. The runner was transported to a nearby hospital and was conscious upon arrival.

At the 2010 Boston Marathon, an AED made the difference in the life of one runner. The 62-year-old runner collapsed approximately two miles from the finish line; although EMS providers responded rapidly, he was lifeless when they reached him. They immediately began chest compressions and applied the AED, which called for a shock. After a focused clinical effort by the medical team and EMS, the runner’s vitals returned.

In Chicago, we’ve used cardiac monitor/defibrillators to assess dysrhythmias in runners who presented with “palpitations or dizziness.” We’ve found that the ability to rapidly assess the cardiac etiology of their condition allows immediate diagnosis and decisive management on the marathon course and at the finish line.

Management of heat illness in marathon medicine is also vital, and the monitor/defibrillators deployed at our event allow for real-time rectal temperature measurement in the most critically ill runners, providing for rapid diagnosis and, thus, on-site treatment to reduce morbidity. During our cooling measures we can continuously monitor the runner’s core body temperature and avoid over-cooling or hypothermic conditions. This additional diagnostic data has enhanced our management of heat illness.

Additional innovative measures continue. Realizing that a rapid response is critical, we plan on providing a chest compression and AED video tutorial to the 12,000 volunteers scheduled to be involved in the next Chicago marathon. This effort should create more bystander emergency response capabilities for race day and provide the greater community with trained personnel long after the event is over.

Conclusion
As marathons increase in appeal, so will the challenge of addressing the variety of runners and their medical conditions. Preventing and treating the incidence of marathon-related cardiac death is a critical part of this challenge. Technology and best practices will continue to evolve, but our role as medical providers and also as community bystanders remains the same: Provide and respond with the best care capable.

Disclosure: The authors have reported no conflicts of interest with the sponsor of this supplement.

References
1. Marathonguide.com
2. USA Track and Field Road Running Information Center, Road Race Participation Numbers Source. Santa Barbara, Calif.: American Sports Data Inc., 2004.

This article originally appeared in an editorial supplement to the September 2010 JEMS as “In It for the Long Run: Best practices for providing cardiac emergency care at marathons.”

 



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