Thursday, June 18, 2020

A Medical Coordinator's Thoughts Amidst a Pandemic

Today I still have a job, my family is well, and my boss has accepted least for now. I am spending my days discussing, arguing, and fact-finding, explaining and teaching about COVID-19. I attend virtual webinars from industry leaders about COVID-19 and the impacts on events. I read about Joe Desena’s Spartan events this past weekend and the efforts to make it safe. I reach out to those smarter than me to inquire about epidemiology, false positives, and rates of infection and ask, “What would you do?” I hear many calling for no large-scale events until we have a vaccine.

I am tired and torn. I am confused about the different state “phases.” I am now reading about the skyrocketing increases in infection rates some states are experiencing as a result restaurants, bars, and other activities re-opening. Then I hear that running a race is no different from going to the grocery store right now.

I worry about our athletes in adaptive sports being pushed to the wayside because they are deemed higher risk. I hear some say it might be more convenient to cancel or postpone the race for adaptive athletes but let others participate. I see some of my elders who are fit and healthy still playing golf and tennis. They are carrying on.

I listened to my good friend who is a respiratory therapist in New York City and the stress she was under in April and May. I was proud to see the USNS COMFORT and MERCY deploy to assist and then disappointed when I saw the low numbers of cases, and maybe how those staffs could have been used to assist in nursing homes across the country.

I look at the vast number of events that have been cancelled and the small race operators who cannot pay their staff or issue refunds; they will not survive this year. I feel for the BQ’ers who will not have the experience of a lifetime in Boston this year. Event after event is cancelled. Some are successfully turning to virtual events and rejoicing in the runners who post their medals and family finish lines.

I miss my volunteers. We are in June and I have not seen any of my loyal medical volunteers since last November. I miss the exhaustion of planning, packing, and rehearsing for the big events. I spend my day working on countless courses of action for hosting an event. We have a small one planned in August, maybe 200 runners. I am worried about heat stroke and breathing issues and of course, the cardiac issues we are seeing associated with post COVID-19 infections.

I plan, check equipment, order some new items, and set up training and meetings. Fire/EMS is too busy to talk and plan right now. COVID-19 and social unrest are their immediate concerns.

Do we change our waivers? Do we require anyone who had COVID-19 to get clearance from a cardiologist? Do we take participants’ temperatures? Should athletes be tested before they come to an event?

I informally reached out to our past marathon medical volunteers to get a sense of what they are thinking. No formal surveys, just asking if they would come and "If yes, did they have any question and if no, why not?" Fifteen percent responded in just a couple of days. The physicians were split 50/50, many saying no because of travel restrictions from their organizations. Most nurses said yes and wanted to know about our Personal Protective Equipment (PPE) standards. Some stated that if our event were to happen, we must deem it safe.

What does safe mean to you? That one is hard to grapple with. Many decisions are before us. Some are in the grey zone while others are based more on ethics and morals. I know others are worried, too. And they are uncertain. I ask that we keep talking and supporting each other and working together to reach decisions and answers that are best for each of our circumstances.

I also ask, "How are you feeling?"

Shelly Weinstein, PT, MS, SCS, ATC (left) with her
sister Maureen Smith, RN.

Wednesday, February 5, 2020

The Medical Impact of Unofficial Runners

There are many reasons participants cheat at races. Most of the time it is unintentional, occasionally it’s about ego or proving prowess or trying to obtain an entry into a prestigious event like the Boston Marathon. In 2015, Runner’s World discussed this phenomenon in an article called “How Common Is Cheating at Marathons?” and analysts like Derek Murphy of Marathon Investigation report on those who cheat.

As the medical lead for the Marine Corps Marathon, I review the data after our events to look for injury trends, heat stroke body temperatures, and other relevant information to improve our support. We often receive runners in the medical tents who are not registered as participants. These are not large numbers; in the last three years we have averaged fifteen medical “bandits.” However, if we were to extrapolate those numbers to the full field, we would be looking at almost 400 bandit participants. Nevertheless, let us focus on the effects these runners can have on medical services.

These bandit athletes may have purchased a bib or swapped with someone. If a runner receives a bib through swapping, once he/she enters the aid station, there is a delay in identifying the athlete because there is no match in the database. If the athlete is conscious, we work to get their demographics with emphasis on age and date of birth and any past medical history. If the athlete is unresponsive, however, trying to obtain personal information or next of kin data is impossible. When this unidentified athlete is transported to a hospital for further care, they must then be listed as a Jane or John Doe. We have no way of contacting family members nor obtaining pertinent past medical history. Additionally, for events like the Marine Corps Marathon which uses a live tracker database, we cannot find the registered runner because we are looking for a person not in the event.

We had a case where a runner was picked up off the course and transported directly to one of our hospitals. There were several runners at this emergency room and we were providing updates to our liaison and the medical team about the participants. The information we sent for one athlete was based on the information in the database but, unfortunately, it was incorrect. She was listed as a 42-year-old female. The medical staff thought they were taking care the female shown in our database, and we reached out to her next of kin. But it was not her; instead, it was her 36-year-old friend. It then took additional time to get in contact with the bandit’s family.

What if bib swapping involves a minor? Most registrations require parental consent for a minor. What if we need to obtain consent from that parent for care? Other considerations might include winning an age group or award—protecting the participant’s own race history and records and insurance claims could be complicated if the runner is using someone else’s bib.

We do not want to discourage athletes from receiving care; the medical team, as always, will care for those in need regardless of who they are. But these types of cases certainly make it more difficult for us to do our job. We all need to work to educate our participants about the risks of bib swapping and running as bandits.

Thursday, December 12, 2019

A Tale of Two Races in One Day

Like many of the Marine Corps Marathon runners this year, October 27, 2019, will stick in my mind for a long time. In my 16 years as the medical coordinator, it was the first time it rained- buckets- 2.5 inches, rivers of water on the road and then the sun came out and it was hot. We hit 80 degrees near the end of the race.  Runners were in water above their ankles at miles 12-14. The water was running like rivers on the side of the road, so all the runners were crowding into the center of the road to lessen the impact of the water. At least we did not have the predicted thunderstorms. However, we did have the Vice President of the United States show up unannounced to watch his son and then stay for an hour to congratulate thousands of runners. 

The impact of the weather on the runners was significant. Cold, wet, and windy conditions produced lots of hypothermia. We had core body temperatures as low as 91 degrees and many in the mid 90s. The bright side to running in the cold and wet was the number of Personal Records (PRs) being set that day. The seasoned runners wore garbage bags on their bodies and shoes until the start of the race. Some had sandwich bags with extra socks to change during the event. Many discarded layers and layers of clothing as the miles went by. Then at 11:13 AM that big yellow ball of heat rose from the clouds and the puddles started to dry up, more clothes were shed and  body temperatures began to rise……….. 106, 107, 108.

We had several runners with hyponatremia, hypothermia, hyperthermia, heat stroke, and blisters. In fact, the blisters and abrasions were everywhere due to the rain. We also had more falls and fractures than our average race due to wet leaves, water, and hidden surfaces. We transported 36 runners; there were reports of several more going to the emergency departments on their own later that night.

What is the take home message from this day? When planning, you need to be prepared for anything and everything. We needed last-minute orders for more ponchos for the roaming medical staff. Generators can short out in pouring rain, making lights dim. Floors in aid stations get slippery and muddy and the gear gets muddy. Runners are muddy and very wet. Tape does not stick; walking on crutches can be hazardous. Paperwork and bibs get wet, tear, and can get lost.

You need to be prepared and you need to be flexible. The best-laid plans may have to be scrapped once you cross the start line. The key is having leaders who can make good decisions in short order and having prepared plans that can flex and adjust. We were given less than a 10-minute notice that the VP wanted to come by. The security plan and egress plan for medical had to flex. He then wanted to stay, chat, and congratulate runners (all during the height of the finish). We did take the opportunity to highlight our medical teams—opportunity knocked!

As any of us who plan, coordinate, provide logistics, and support all the other pieces of events can tell you, lots of preparing, planning, formulating, and rehearsing can go a long way to be ready for anything on the big day.

Tuesday, July 2, 2019

"That's a full-time job?"

I routinely get that response when someone asks me what I do for a living. It is usually preceded by my statement, “I’m the medical operations coordinator for the Marine Corps Marathon Organization.” I then further explain we have seven event weekends throughout the year, with 18 events ranging from one-mile fun runs to a triathlon and now an ultra. Our participants range in age from five to eight-six. The raised eyebrow stays, as they wonder what it takes to host and execute an event. These comments emanate from runners and non-runners alike.

For runners, the experience is typically this: they visit the exposition, pick up their bib and t-shirt, shop from a few vendors, maybe sightsee, eat a good dinner, and then hope to sleep well before they toe the line. On race day, hopefully, they cross the finish and receive their bling, get some food fuel, hang out for a beer, and talk about their times. A few will earn an award. Many will have used porta-potties and taken water or food from a station along the course. Some will visit the aid stations; some will lose contact with their running buddy and go to lost and found. But most have no appreciation of the behind-the-scenes Herculean efforts undertaken to be “race day ready” or as we call it here at Quantico MISSION READY!

Each event has its own signature and theme and identity and uniqueness. What we all have in common are the checklists and policies and protocols that need to get done in preparation for race day. The end of the event is just the beginning for race organizations. Media posts go out. All the equipment and supplies need to be packed up. The clean-up—oh the clean-up. Cups and trash and discarded clothing all need to be picked up and disposed of properly. Usually, the day after the event, permits and venues have to be secured for the next year. Phone calls start coming in about lost items, missed timing mat check points, and ill-fitting t-shirts. In the following week, bills need to be paid to law enforcement, Fire/EMS, and vendors. Participant feedback is solicited. Reports are completed to note what improvements are needed for next year.

For several of our organizations, there is already another event to be planned and executed. Marathon planning is year-round. There are so many aspects that need review, completion, and verification. Organizations have different structures, yet we all deal with finances, business, marketing, sponsorship, logistics, vendors, security, legal, medical, timing, and results. Each of these areas has a multitude of smaller areas of focus to complete. So yes, it is a full-time career.

I invite you to share your “ah ha moment” of what you learned about marathon planning that you didn’t know before and I invite to come spend some time with me or other coordinators to see and experience all the moving parts.

Friday, November 30, 2018

Where are the Bandaids?

“…needed more bandaids,  …..the supplies seemed to be short on bandaids, …..we couldn’t find the bandaids.” These were some of the feedback comments we received as we closed out our 2018 Marine Corps Marathon this year. As the medical coordinator, the comments initially made me a bit annoyed, but then I sat back and thought there are some more fundamental issues here in the planning and executing of large venue events.

Our warehouse of medical supplies and equipment holds several thousand dollars’ worth of various consumable supplies. We have bandaids, we have roller bandage gauze, we have 4 x 4 sterile and non-sterile gauze. We also have Tegaderm™, Opsite™, New Skin™, Coban™, sticky back felt, moleskin, Durabond™ and many other wound care dressings. There are so many more dressings and bandages available on the market.

Care in the field is very different than care in the clinic. That includes your supplies. Most of our events rely heavily on our volunteers. They are the key to our success in our medical tents. They come with a lot of enthusiasm and giving hands and many of them come with little understanding of supplies that are most useful in the sporting environment.

Adhesive bandages with gauze pad center (the generic definition of bandaids or Band-Aids™) work in many environments but not once an athlete is sweating. They just don’t stick, they don’t work over a joint or in a shoe. Sometimes you can use benzoin of tincture, betadine or other glues to make it stick better but there are better supplies that work in the athletic environment.

Our role in educating our volunteers and staff includes protocols and algorithms but I think it also means giving them a bit more lay of land in the logistics area. We stock eight types of tape—some for the musculoskeletal practitioners, some for the IV’s and the duct tape—in case everything else fails. Some might say that is way too many. For our events these are the ones we use and our AT’s and PT’s like and have asked for over time. We train our supply petty officers and they pack their gear but on race day they cannot be everyone where in the tent.

So maybe for next year I’ll create a go-by with a catalogue of our supplies and how they can be used.

Thursday, August 2, 2018

At What Cost? The Price of Safety

Yesterday [July 31] I attended the Blue Ribbon Study Panel on Biodefense: The Cost of Resilience: Impact of Large Scale Biological Events on Business, Finance and the Economy. Former Representative Jim Greenwood facilitated this meeting with the panel’s co-chair, former Senator Majority Leader Tom Daschle. Panel members included Former Senator Joe Lieberman, Former Governor Tom Ridge, and Former Homeland Security Advisor Ken Wainstein. Testimony to the panel included Congressional Representatives; representatives from the pharmaceutical industry; FedEx; ExxonMobil; World Bank; and Dr. Lou Marcianci, Director of the National Center for Spectator Sports Safety and Security, from the University of Southern Mississippi.

It was truly an interesting day. In their discussions, the various presenters offered comments ranging from the need for federal oversight, financial support, integration of the public private partnerships in various areas and at various levels of the government involving biodefense, and more tactical discussions including the best way to remove a drone from a mass gathering. You are probably asking how this affects us as members of the International Institute of Race Medicine (IIRM). 

Each of our events coordinates and communicates with law enforcement and emergency services. We participate in the development of the Incident Action Plan (IAP) and we develop our own Emergency Action Plans (EAPs) for severe weather, road closures, and a sentinel event. Most of this is behind the scenes; runners and spectators are not aware of all the planning and work that must occur to make our events safe. That safety, however, is costing more and more. Major events spend millions in law enforcement and emergency services. Before 911, local law enforcement supported the Marine Corps Marathon with a big smile and the promise of a shirt. In 2017, we were required to add blocking vehicles in several locations on our course. 

For those of us who answer to boards, sponsors, governments, etc., what is the financial tipping point for us? Is there a registration fee ceiling that our participants will not exceed? As the number of events grow but registration numbers remain flat or decrease, how do we keep our events safe, exciting, and memorable for our participants and spectators without breaking the bank? I always comment that no one focuses on medical at our events except us, and I still agree with that statement. The expectation is we are trained, ready, and prepared to handle what comes our way. Runners do not plan to visit aid stations, enter emergency rooms or stay overnight at a hospital (or worse, not come home). As we continue to develop more robust safety plans and add specialty law enforcement and emergency services, how do we educate our customers? How do we mitigate risk? And how to we afford to stay in business?

Tuesday, May 8, 2018

Athletes with Disabilities: Safety Considerations

More and more physically challenged athletes are participating in traditional running events. Requests for entries for wheelchairs, handcycles, and “pushers” continue to increase. Renowned wheelchair athlete Craig Blanchette a former Olympian and pioneer in wheelchair racing, sued race owner Competitor Group, Inc. for gross negligence due to an injury at the 2014 Rock ‘n’ Roll marathon because race organizers altered the course without notifying him. A San Diego jury awarded him $4 million this week. Blanchette said that race organizers changed a portion of the course the morning of the race, on 11th Avenue near B Street, and did not inform him.

Some events do not allow wheelchair or handbikes in their events due to safety and security concerns. This note is from the Footlevers Blue Ridge Marathon website:

The Foot Levelers Blue Ridge Marathon course is designed as a road running course. Multiple athletes with disabilities have inquired over the years about completing “America’s Toughest Road Marathon” using handcycles and wheelchairs. In 2014, organizers permitted a trial run of the half marathon course with two athletes with disabilities using handcycles. One athlete was a pro handcyclist, and the other was a recreational handcyclist. After observations of the athletes on the course and feedback from the athletes, it was decided that having an open field of handcyclists would not be safe for the race, given the course layout, extreme terrain, and that steep portions of the course are not fully closed to vehicular traffic. Organizers have also consulted with professional wheelchair racers, and these athletes indicated that the grades on the course are too dangerous for safe competition of racing wheelchairs.

USATF provides guidance and has provisions in place for Athletes with Disabilities to compete in wheelchairs; however, USATF does not accommodate handcycles in competition. USATF has a very specific policy designed to assist race directors so they can deal with the complex questions surrounding disabled athlete participation. Members of the Road Runners Club of America (RRCA) should refer to the USATF policy on Americans with Disablities Act (ADA).

In 1979, the RRCA published “Guidelines for Wheelchair Athletes.” The purpose of these guidelines is to provide information for event directors and athletes. Hopefully, these guidelines will facilitate the inclusion of athletes with disabilities in road racing events and foster discussions among event directors, members of the disabled community, law enforcement and public safety personnel and others involved with a particular event. The guidelines are not intended to cover all events or situations.

While the safety of all participants in a running event remains the paramount concern of any event director, these guidelines will help event directors focus on real safety concerns related to a specific disability and not concerns based on false perceptions, stereotypes or generalizations about athletes with disabilities.

Pushing disabled athletes in a sport chair has become more and more popular. From time to time, RRCA members have struggled with having a “no stroller” policy and complying with ADA accommodations for events. If the persons seeking to enter the event meet any age restrictions placed on participation, then the event needs to make reasonable accommodations to allow a disabled athlete to be pushed in a wheelchair in the event by an able-bodied participant. This is in accordance with providing access to the event. Race organizers need to make decisions regarding registration of one or both athletes.

Should age restrictions apply as they do with able-bodied athletes? How do race organizers inform participants of terrain concerns or undesirable or non-negotiable terrain for a wheelchair? Concerns also include hairpin turns, elevations greater than 10% and steep hills that may increase speeds greater than 20 mph.

Recently the Marine Corps Marathon was informed by law enforcement agencies that wheelchair and handcyclists MUST have a reflective flag that is 4-6 feet in height to allow for visibility of the athletes in crowds. The MCM will be sending these athletes the information and requirements. What happens if the athlete shows at the starting line without the flag? Should they be pulled? Is it the responsibility of race organizers to place a flag on their equipment prior to the start?

What about requests for service animals to participate in events? Should organizers add veterinary professionals to the support staff?

These topics seem to be the third rail in many circles but it behooves all events to have the discussions to share their policies and better inform and work with athletes with disabilities to encourage fitness and participation where possible.

What are your thoughts? How do you interact with these athletes?