Major Incidents

Beach2Battleship Triathlon Highlights Importance of Preparedness for Medical Response Team

Issue 12 and Volume 40.

The conclusion of the seventh year of the Pharmaceutical Product Development (PPD) Beach2Battleship triathlon represented a year’s worth of training and personal accomplishment for 1,512 athletes. It also represented the accomplishment of a comprehensive medical response team that included a regional medical center, the state medical assistance team, an EMS system and dozens of medical volunteers. This incredible undertaking required months of careful planning and preparation, a large multidisciplinary team of medical professionals and support from across the state. In the 2014 race, more than 80 medical staff provided care for more than 200 participants over 18 hours.

The PPD Beach2Battleship triathlon is headquartered in Wilmington, N.C., although the course runs through four counties. It includes a 2.4-mile swim, a 112-mile bike course and a 26.2-mile run. It was named one of the Top 5 Ironman triathlons in the world by Triathlete Magazine and attracts athletes and visitors from all over the world.

The course starts in Wrightsville Beach, where athletes swim through a channel off the Intracoastal Waterway. The bike course takes competitors into neighboring Pender County, Sampson County and Bladen County, before finishing back in New Hanover County. The final leg of the race, the marathon, runs through Wilmington and ends just across the Cape Fear River from the USS North Carolina Battleship— hence the name “Beach2Battleship.”

Because of the scope and the arduous nature of the race, medical professionals must be prepared for dozens of injuries. Rather than crowd the local EDs, a mobile field hospital and a specialized EMS response are coordinated to handle the influx of medical needs.


To provide medical care for such a large group during a grueling test of physical endurance, preparations started 10 months in advance. The team that coordinates and leads the medical response includes Hans Edwards, New Hanover Regional Medical Center’s (NHRMC) healthcare preparedness manager for the southeastern region; Aaron Kasulis, battalion chief and manager of EMS field operations for NHRMC; and Eileen McConville, director of volunteer services at NHRMC.

Recruitment for the medical volunteers began early, with the majority of volunteers coming from NHRMC and NHRMC’s Coastal Family Medicine Residency Program. EMT, paramedic and nursing students from the University of North Carolina at Wilmington, Cape Fear Community College, and Campbell University also provided medical support.

“Many of our volunteers come back every year and relish the opportunity to work at such a fast-paced and exciting event,” said McConville. “We recruit registered nurses, physicians, physical therapists, nurse assistants, medical assistants, even nonmedical support personnel who can help us check people in. All of these roles are crucial to handle the number and variety of injuries and illnesses we see each year.”

For the Beach2Battleship Triathlon, 80 medical staff provided care for more than 200 participants over 18 hours.

To prepare a fully functioning mobile field hospital, Edwards needed to recruit a team with a wide range of expertise, so he recruited volunteers from the eight State Medical Assistance Teams (SMAT), Type II, which are based at Level 2 or 1 trauma centers. Meals and housing were also arranged for the SMAT members at the Leland Volunteer Fire/Rescue Department.

Just weeks before the race, an inventory of supplies and medications was taken and equipment was inspected and prepared for deployment. A list of the 64 SMAT member volunteers was finalized and an EMS incident action plan was prepared that detailed EMS coverage throughout the event and how that coverage would integrate with SMAT’s mobile field hospital at the finish line. It also outlined the roles of 15 paramedics on bikes, the transport and quick response units, as well as EMS operations leadership.


For the Beach2Battleship Triathlon, 80 medical staff provided care for more than 200 participants over 18 hours.

In all, more than 80 medical staff provided care for more than 200 participants over 18 hours. Photo courtesy Jeremey A. Davis

Volunteers and staff arrived the day before the event to help set up the five-tent mobile field hospital. This hospital included 22 treatment beds with six high-acuity and 16 low-acuity areas, a point-of-care testing area, a supply area and triage. A nearby trailer served as a respite area for staff and could be quickly converted to a patient care area in the event of a medical surge.

It took more than 40 volunteers to raise all the tents and prepare them for patients and staff. The field hospital has to be prepared to treat not only the athletes, but any of the thousands of spectators. Race promoters brought medical demographics of race participants, including name, age, next of kin, medications, allergies and a brief health history, to be stored at the field hospital for reference.

“We have volunteers from all over North Carolina, many of them traveling 300–400 miles to help with this event,” said Edwards. “It’s a great opportunity for the [SMAT] teams to practice their deployment and test out new procedures that they can use at home.”

As the SMAT was making its final preparations at the finish line, NHRMC EMS worked to finalize logistics at the starting point. Kasulis coordinated with the town of Wrightsville Beach to block off areas for swimmers to exit the water and enter into a warm water rinse tent.

A nearby medical tent was stocked with hundreds of towels and linens, and generators were checked and placed for efficient deployment. Kasulis assigned logistical roles and conducted a final walkthrough with EMS staff. NHRMC EMS had already received approval from its medical director to triage and transport patients to the mobile hospital during the race, rather than the hospital’s ED.

The EMS incident action plan was distributed to all agencies involved, including the 9-1-1 field operations staff. The goal was to involve the 9-1-1 field operations staff as little as possible, but circumstances can arise in which additional help is needed, so situational awareness for the team was critical.

“I think one of the keys to our success with this event is that we have really worked to integrate our response with all of the agencies involved,” said Kasulis. “We have one incident command center where we coordinate the response of all the agencies, including local police departments, sheriff ’s departments, EMS teams, fire departments, mobile field hospital staff and HAM radio operators stationed throughout the course. Because we’re able to run all of these communications through one centralized command, we can operate more efficiently and the event can run more smoothly.”

These complex and detailed preparations by each agency help ensure a seamless operation that keeps the burden of a large-scale event from taxing the existing medical needs of the community.


At 6:00 a.m. on the day of the event, Kasulis arrived at the starting point. He checked in with the medical volunteers, making sure everything was ready to go. He coordinated with event participants as they arrived to make sure there were no special needs—often, at least one diabetic requires a blood sugar check from EMS prior to or after the swim portion.

EMS had one ambulance with two medics, one gator with one medic, and one supervisor medic on site for the first leg of the triathlon. Two staff members from SMAT were present to monitor generators and a warming tent.

At 7:25 a.m., 1,500 people began to jump in the water to start the race. A warm shower tent to rinse the salt water and provide some immediate rewarming awaited each swimmer while Kasulis looked for signs of athletes in distress. EMS crews were on the dock with their gear watching for swimmers in fatigue as they came from the water. First responders were also out in the water observing the swimmers for problems. The athletes were required to have wetsuits with caps that clearly indicated whether they were a half or whole marathon competitor. This helped EMS gauge expected stamina levels in each of the athletes.

By 9:00 a.m., half of the swimmers had pulled themselves from the water and were on their way to the 112-mile bike course. One swimmer cut his head on some barnacles and he needed butterfly sutures and a cleanup before continuing with the race. About a half hour later, a call came through saying a swimmer was in distress.

One of the first responders assigned to paddle board alongside the participants noticed the swimmer in distress and went to his aid. While the swimmer was being brought to the dock via boat operations, he slipped into cardiac arrest. EMS staff members continued resuscitation efforts at the dock. Kasulis contacted Edwards with the swimmer’s bib number so pertinent medical information could be obtained from the medical database, which was then sent back via electronic communication. As resuscitation efforts continued, a 9-1-1 field operations unit was called to assist and transport the swimmer from the scene while additional EMS staff still observed swimmers coming from the water.

While the swimmer was being taken to the medical center, the bike course began to get busy. Three crashes led to participants needing transport to the hospital. A quick response vehicle waited on the course to respond to any medical needs. At this point, only a few minor scrapes and bumps were addressed by EMS and the medical volunteer tent.

For the Beach2Battleship Triathlon, 80 medical staff provided care for more than 200 participants over 18 hours.

Volunteers from the state medical assistance team check supplies in the mobile field hospital. Photo courtesy Chris Barden/New Hanover Regional Medical Center

Around 10:30 a.m., staff for the mobile medical hospital and triage tents began arriving. Edwards conducted his final walkthrough while Kasulis moved EMS operations command to a bus serving as a central command center in downtown Wilmington. Two EMS bike teams and a new ambulance crew with two medics came into service. Quick response vehicle staffing for the bike course remained until 5:00 p.m. and, fortunately, only needed to respond to one more bike crash—the fourth of the day.

As the bikers started to arrive to exchange their bikes for running shoes, EMS staff looked on to identify struggling athletes. By this point, dehydration was a primary concern.

The transition was smooth and at about 2:00 p.m., half of the athletes had begun their run. Multiple medical stations were staffed throughout the 26.2-mile course, working in collaboration with the EMS bike response teams. The staff members of the mobile field hospital and triage tent were ready as the first runner crossed the finish line at about 2:30 p.m. Two crews armed with wheelchairs and stretchers watched and observed. The triage tent was about 150 yards from the finish line, so simple transportation devices were critical. If needed, runners were escorted to the medical triage tent where a screening was conducted. If further care was required, a patient flow facilitator assigned a bed inside the field hospital and notified the event communications center of the patient’s assignment. The triage nurse pulled the patient’s chart while the patient was taken to the assigned bed, a report was given and care was transferred to the field hospital staff.

“The use of a patient flow facilitator was new this year,” said Edwards. “Our volunteers last year gave us feedback that the patient flow wasn’t as smooth as it could have been, so we added this new role and it worked very well. That’s one of the great things about this event. We learn and get better every year.”

By this point, 25 patients had been seen by medical staff. As 5:00 p.m. approached, the mobile field hospital was getting busy, and EMS operational leadership and bike teams were changing shifts. A handful of runners were now receiving fluid rehydration via 1–2 liters of normal saline. Cramping was another frequent problem, requiring some Benadryl (diphenhydramine) injections. Even the experienced paramedics on the bike team had to be cautious of fatigue and dehydration since they were constantly moving.

At 7:40 p.m., a runner wasn’t responding well to medical treatment inside the medical tent and the decision was made to transfer him to NHRMC. As he was being prepared for transport, another runner was being evaluated on the course, and was deemed severely dehydrated and in need of transport to the medical tent. With two patients needing transport, 9-1-1 field operations was again contacted to provide care and transport to NHRMC for the first patient, while the other was transported to the medical tent.

During the final hours of the race, the pace of medical need slowed, and just after midnight, the medical tent closed. Overall, 43 patients were treated in the medical tent, the lowest number treated at the field hospital in the event’s seven-year history. The average number of patients cared for in the field hospital is about 60, but that number has been as high as 96.


The medical staff treated hypothermia, jellyfish stings, cuts, fatigue, cramps, nausea, dizziness, seizures and a host of other complaints. But the relatively low numbers of people needing medical care suggested that this was, in part, due to the moderate weather during this year’s event.

“Typically, we’re buying our supplies for the race a month in advance, so it’s difficult to plan for how the weather will affect our supply needs,” said McConville. “During particularly cold years in the past, we’ve run out of soup and hot cocoa and during warmer years, we’ve run out of some of our cooling supplies. This year, the weather was so moderate that it really made it easier on everyone.”

Even though the event was considered a success, the team always looks for ways to improve. Whether its additional supplies that would be helpful to the team or personnel changes that might help the event flow more smoothly, preparations for next year begin almost immediately.

“Based on feedback from some of our volunteers, we’re looking at testing some new heating and cooling options for the athletes,” Edwards said. “We’re considering cooling vests or chairs, similar to what’s used for firefighter rehab.”

For the Beach2Battleship Triathlon, 80 medical staff provided care for more than 200 participants over 18 hours.

The bike and marathon legs of the triathlon are staff with two bike teams and three specialty vehicles. Photo courtesy Chris Barden/New Hanover Regional Medical Center

Another consideration is additional electronic communication options for the medical aid stations.

“The mobile field hospital used an iPad to chart patient information,” said McConville. “But we realized it would be helpful if the medical aid tents had some too, so that the patient information could start at the medical aid tents. It’s an option we’re considering for the future.”

Although there were plenty of medical staff and volunteers, locations of the staff are something the EMS team is reviewing.

“We’ve had paramedics stationed at the beginning and the end of the swim course, with medical volunteers in the water and on boats throughout,” Kasulis said. “But we’re looking at placing additional paramedics at the halfway point of the course where the swimmers take a turn. We’re also looking at placing paramedics on the volunteer fire and rescue boat that monitors the course, so that we’re able to start treatment before the athlete even gets back to land.”

Regardless of any changes made for future events, the team agrees that the most critical component of a successful event is communication.

“Aaron, Hans and I have been working on this event together since it started seven years ago,” McConville said. “We each know our responsibilities and we are in constant communication long before event day. I think that’s why we’re able to be successful. We each bring our specific areas of expertise and we work together as a team to make sure that every participant who needs medical help receives the best possible care. It’s a rewarding experience.”

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