From Start To Finish

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June/July 2002

By C.A. Wolski

Clare Safron-Norton, PT, MS, OCS, and another Marathon Medical Clinic volunteer warm and rehydrate a runner with hypothermia.

If the Boston Athletic Association (BAA) Marathon Medical Clinic was at the finish line of the first Marathon, the legendary Greek messenger Pheidippides probably would not have died of exhaustion. For the past 25 years, the clinic has aided thousands of injured and exhausted runners in the Boston Marathon, the oldest US marathon.

“People would survive if we didn’t have the medical care, most people wouldn’t die, hardly anyone would, but they wouldn’t feel well for a few days,” says Joan Casey, RN, CCRN, finish line medical tent coordinator. “What we’re doing is providing treatment for a condition that could be worked out in 2 or 3 days, but this way they feel better immediately, they’re treated immediately, and they like that; that’s what they expect.”

The clinic, which is sponsored by the BAA, started modestly with 25 volunteers. “Twenty-five years ago, the president of the American Medical Joggers Association, who was chief of hematology at the hospital I worked at, ran [in] the marathon and he felt that they needed a more organized medical station at the finish,” says Casey. “There were a few people there, but it wasn’t really organized. So he asked me if I could organize a few people to be at the finish.”

Today the team consists of more than 1,000 volunteers, and Casey no longer has to bribe potential participants with promises of T-shirts and sandwiches as she did a quarter century ago. “Now there’s an application to fill out or they can call the BAA to apply,” she says. “The thing is, though, we have to turn away a lot of people who apply.” The medical team is made up of physicians, nurses, intravenous nurses, podiatrists, athletic trainers, physical therapists, emergency medical technicians, massage therapists, and medical and allied health students from area colleges and training programs.

WELL-CHOREOGRAPHED CARE

Clinic Offers Help for the Day After

When the Boston Marathon ends, medical care does not. In the 3 days following the annual event, a Post Marathon Injury Clinic is held at Newton-Wellesley Hospital, Newton, Mass, to care for those who may still be feeling the effects of the race. “We’re seeing the first time marathoner who really is suboptimally prepared,” says Jim Zachazewski, MS, PT/ATC, SCS, coordinator of the Post Marathon Injury Clinic and director of rehabilitation services at the hospital. “We’re seeing the general person from the public that runs a 3 hour and 28 minute marathon—we’re not seeing the 2 hour 10 minute runner.”

Maximizing Exposure
The clinic was started in 2001 as a way for the hospital to capitalize on the race. “This is the hospital’s way to support the community at large as well as partnering with the Boston Athletic Association (BAA) to maintain the Boston Marathon as the world’s race,” says Zachazewski. “It’s also a marketing [tool] for the hospital as well as the doctors. We do this completely free of charge to the runners or the public who come in. It’s really more of a service to the marathon community. It’s not meant to be a money maker for us and never was conceived to be a money maker.” The clinic is sponsored by Newton-Wellesley Hospital. The clinic is staffed by medical personnel—physical therapists, athletic trainers, podiatrists, nurses, orthopedic surgeons—from the hospital who donate their time.

While the BAA Marathon Medical Clinic deals mostly with issues of dehydration and fatigue, the Post Marathon Injury Clinic resembles an orthopedist’s office. “We see a lot of overuse orthopedic problems and a lot of feet,” says Zachazewski. “Last year we had two or three cases that were not musculoskeletal in nature. [This year] we had one guy with abdominal pain and cramping, another woman who had some physiological issues going on, some anemia and problems like that, which required some blood work.”

Injuries are treated in a variety of ways from education to ice to dressing the injury or all three. “These are walking wounded who are sore, [who just need] ice and maybe a little massage,” says Zachazewski. “It’s really a lot more runner education.”

Free Service

Though the clinic is free for legal reasons, attendees are treated just like patients. Consent forms are signed and a chart is started. If an injury is serious, then the patient is taken to the emergency room and admitted, just as they would if they had been seeing their regular physician.

The clinic is marketed in a variety of ways, including local newspapers and television and radio public service announcements. Most of the patients, however, find out about the clinic through a flyer included in their registration packets. And it is not a requirement that patients have been marathon participants. “You do not have to have run in the marathon in order to come in and partake of these services,” says Zachazewski. “[However,] we ask that you be a runner, somebody physically active along those lines as opposed to the 78 year old with a diabetic foot.”

Though the clinic gets a demographic as diverse as the marathon, the number of patients is much smaller than those seen by the marathon medical clinic. Last year, the clinic had 108 patients; this year it had 68. Though the clinic had less patients, Zachazewski says that it will continue next year, though it may be held only two nights instead of three. This year’s clinic saw more runners with stress fractures and more consultations with internal medicine specialists. Zachazewski adds that since the clinic is still in the “learning curve” phase of its evolution, it may take a few years before all of the rough spots are ironed out.

The number of patients does not matter to Zachazewski and his colleagues. “It’s fun, it’s different,” he says. “This is our way of helping the BAA maintain the Boston Marathon’s stature as the number one race in the world.”

What has not changed is the kind of medical care the group provides to the 19,000 to 20,000 runners who participate in the race each year, many of whom, like the legendary Pheidippides, are first-time runners. On the face of it, the task of providing care to that many people can seem overwhelming, but not to medical tent organizers. They can predict with almost scientific precision exactly how many injured runners they are likely to see in a day by just checking the weather report. “We know, based on a 20,000 race figure on a mild day, we’re going to probably see 3% to 4% of that total,” says Chris Troyanos, ATC, medical coordinator and one of the cadre of Casey’s early volunteers. “On a normal day we’ll see between 350 and 500 casualties in [the medical] tent. On a moderate day we’ll see 5% to 7%, a heavy day 7% to 10%, and an extreme day would be anything above 10%. So weather is a huge factor in what we see and how we plan.”

Because of the mild weather this year, there were few injuries. The team treated between 450 and 500 people, which Troyanos says, “we could do without even blinking” because of the system they have in place, adding that the team could treat as many as 800 without being overly taxed.

“Most of the injuries are non-life-threatening and related to the weather,” says Troyanos. “On average it’s 55°F, so what we’re normally getting is hypothermia— body core temperatures are going down,” he says. “We have more cold-related problems than heat-related problems. This year we had a little bit of both because of the weather changes [along the route]. One of the issues we’re starting to see more and more is hyponatremia—water intoxication. We see a lot of blisters, different types of cramping, but that’s more of a hypo/hyperthermia situation and dehydration. You’re obviously going to see a lot of podiatry-type issues. That’s standard in any race. You’re going to see the occasional ankle sprain. You will see someone with a stress fracture in a foot or a lower leg, but that’s a training error; that didn’t just occur at the race. That built up over time as they were training prior to the race.”

LOGISTICS

The goal of the medical clinic is to treat runners on-site without sending them to area hospitals; this year only about five people had to go to a hospital emergency department. The rest were treated by the BAA Medical Clinic. The finish line medical tent takes up an entire city block—about 55,000 square feet—and has 210 cots. In addition, there is a smaller, auxiliary tent to handle overflow. The main tent is broken up into smaller sections with eight to 10 cots overseen by a team that includes one physician, an IV nurse, a nurse, a physical therapist, an athletic trainer, a podiatrist, a medical student or two of any discipline, and a medical records scribe for each section. Along the route there are 26 Red Cross first aid stations.

Medical treatment is proactive. “We’re very aggressive,” says Troyanos. “Boston was one of the first, if not the first, marathon in the United States to get very aggressive with IV therapy. In that medical tent, in that block, we can hang an IV anywhere; we string lines throughout that tent, so all you have to do is find a yellow line and clip your IV on and get that patient started with an IV. And the normal rule of thumb is that [patients get] normal saline versus any other type of IV fluid.”

Local emergency medical system crews bring any runners within the city limits requiring medical care to the finish line tent first and not to an emergency department. If a runner requires more serious or emergency care, there are hospitals at six-mile intervals along the marathon route, and there are three 2 minutes away from the finish line tent.

At the beginning of the race, 25 athletic trainers are in the starting chutes. At the end of the race, a 225-person sweep team trolls a four-block area adjoining the finish line with wheelchairs, searching for runners who may require medical assistance and cannot make it to the medical tent on their own. Among the crew are 25 of Clare Safran-Norton’s Simmons College physical therapy students.

TEAM WORK

Clare Safran-Norton, PT, MS, OCS, who has been team captain of physical therapists in the finish line medical tent for the past 6 years, says the day is fun and rewarding for her and her students because of the team medical approach. “It’s a wonderful experience for my students and colleagues working as an interdisciplinary team. In terms of physical therapy, the other health care providers look to PTs for massaging and stretching of the muscles and getting people walking again,” says Safran-Norton, who is also an assistant professor of physical therapy at Boston’s Simmons College and a clinical specialist at Brigham and Women’s Hospital. “We’re a team assigned to each other and we all help each other out. Everybody administers fluids, everybody can take vital signs, and everyone watches runners’ temperatures. We all help each other take care of the runners.”

Because of its high profile and because it no longer requires a qualifying event, the Boston Marathon attracts runners of all levels from all over the world. This year, runners from 75 countries and every US state participated in the marathon. The medical clinic rarely has to treat the top 200 runners, who are almost always professionals, but when they do, Troyanos says, the team knows to expect trouble. “If you see that they’re having trouble, you know you’re in for a very difficult day,” he says.

Every runner who is treated has a detailed medical record created for them. “We have an extensive medical records program and also a computer tracking program,” says Troyanos. “I can go back to see if my scribes and my medical people in the tents are doing the right thing and reproduce what was done on any patient.”

The BAA Marathon Medical Clinic wants to start a new organization to help other race directors originate standards of care for the plethora of running events held around the country.

MORE MARATHONS, NOT ENOUGH MEDICINE

Surprisingly, with all of the countless marathons and 5k and 10k runs in the United States, medical care such as that available at the Boston Marathon and other high-profile races is still uncommon. Troyanos says that there is a new running boom that has attracted a “staggering” number of runners to events across the country. “We’re looking at starting a new organization to help disseminate information and help race directors and marathon directors develop a standard of care, which, in my opinion, there is not enough of,” says Troyanos. “There are some standards set out in regard to hydration, but I think other standards need to be in place.”

There are a number of steps that must be taken in order to develop a successful medical plan for a race. Some of these steps, on the surface, seem to have little to do with medical care per se. “You really have to look at everything,” says Casey. “You want to look at your weather conditions, you want to look at the problems when people are running on asphalt, what kind of condition the road is in that they’re running on, what kind of medical care you have for the whole route. Do you have a different standard for the beginning and the end? You really have to know your route, what your route looks like, and whether there are any changes in care. Years ago we took care of people who were sick at the finish and we didn’t think about anything else. But now we try to make it so they’re not sick. We try to give them information prerace; we try to tell them how to protect themselves from the elements—from the heat, the cold, low sodium, muscle cramps.”

Safran-Norton adds that the steps that organizers have to take to set up a medical system from scratch include creating a core interdisciplinary group and finding sponsors to provide medical supplies.

In addition to medical care at the race, marathon organizers provide preventative care tips in the race packets and at a sports exposition preceding the event, at which Safran-Norton and her students also volunteer. Medical organizers offer numerous briefings for the medical staff in the days leading up to the race.

The medical care is a key element in the continued success of the race. “[Because] we have an excellent reputation for providing a very high level of care, the marathon attracts more runners, which in turn increases tourism for the city,” says Safran-Norton. “People know they’ll be in good hands when they’re here.”

C.A. Wolski is associate editor of Rehab Management.

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June/July 2002