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New for Marathon Medical Management: A Postrace Clinic

The medical plan for marathons and other endurance events has traditionally focused on care provided on the course and at the finish line. However, planners of the Boston Marathon have taken the concept a step further by teaming up with a hospital on the race course to offer a postrace clinic to treat the "walking wounded."

"We're seeing the survival of the fittest," says James E. Zachazewski, MS, PT, ATC, SCS, director of rehabilitation services at Newton-Wellesley Hospital who has worked at the postrace clinic. "They're not the elite athletes, but those who finished, did a great job, and achieved their goal, and their bodies are broken down."

Fulfilling a Need

The walk-in clinic, based at Newton-Wellesley Hospital in Newton, Massachusetts, just finished its second year, says Zachazewski, who helped develop the clinic model during its first year. He says the idea for the walk-in clinic came from two Newton-Wellesley staff members who are part of the marathon's medical team. "They thought there was something our hospital should be doing. The marathon runs right by our front door, and between miles 5 and 20, we're the closest emergency department," Zachazewski says.

They approached Boston Marathon officials with an idea for a postrace clinic, and they received an enthusiastic response that resulted in the formation of an official relationship between the hospital and the Boston Athletic Association. Historically, the marathon's medical plan included premarathon education and medical stations, he says, and a formal postrace clinic fills a void. "The clinic closes the circle on marathon medical management," Zachazewski says.

Zachazewski says data from the postrace clinic is shared with marathon officials. For example, he notes that 77% of the 107 treated the first year did not seek care along the course or at the finish line. That information may help race officials fine-tune their medical plan, and injury trends may help them refocus their injury-prevention efforts.

How Does It Work?

The clinic, located in the hospital's preoperative suites, is offered free to runners during the 3 days following the marathon. The facility is open from 4:30 pm to 7:30 pm, and patients can be seen on a walk-in or appointment basis. The clinic is promoted in prerace materials, in the race program, at nearby hotels where many runners stay, and in local newspapers.

Clinic staff includes orthopedists, podiatrists, physical therapists, nurses, and athletic trainers. An internist is on call, if needed. The patients first go through triage run by nurses and trainers, and then are assigned to the appropriate physician. Zachazewski says the wait times were minimal, and patient visits averaged 22 to 25 minutes.

Physician members of the healthcare team donate their time to staff the clinic, and the hospital pays for other staffing as well as x-rays, lab work, crutches, braces, casting materials, or any other supplies. Patients who have acute medical conditions that can't be treated in the walk-in clinic are admitted to the hospital's emergency department; at that point, the patient becomes responsible for the medical costs.

The clinic provides a valuable service to race participants and any runner in the local community. It's also an excellent public-relations opportunity for the hospital, Zachazewski says. The contract with the Boston Athletic Association allows the hospital to use the marathon name and logo in promotional materials for the postrace clinic.

Injury Trends

Alfred W. Hanmer, MD, an orthopedic surgeon at Newton-Wellesley Orthopedic Associates and at the postrace clinic, says most patients that seek care have minor to moderate musculoskeletal injuries such as iliotibial band friction syndrome, quadriceps and Achilles tendon inflammation, excessive muscle soreness, shin splints, blisters, and toenail problems. The most serious cases were acute stress fractures in a few patients, chest pain in one patient, and lingering effects of dehydration in one patient.

Hanmer and Zachazewski say the injury profile of patients treated in the clinic was what they expected, given the distance and rigor of the marathon course. "Some are extraordinarily invested in completing the race, and they will finish whether walking or not," says Hanmer. The biggest mistake race participants make, he says, is inadequate stretching, hydration, and nutrition.

Seeing the range of injuries helps Hanmer, himself an endurance event participant, guide his active patients to become more aware of their bodies so that they can recognize problems when they first surface. "The injuries we treat are often the same injuries they've had all along," he says. "I tell them that they should be careful if they even feel the presence of a body part, such as a knee. That can be an early sign of injury." He says working at the clinic also reinforces the importance of preventive stretching for marathon runners, particularly of the iliotibial band, hamstring and quadriceps muscles, and the Achilles tendon.

Lisa Schnirring

Field Notes

Internists Rate Students' Musculoskeletal Competency Low

In 1998, two researchers from the University of Pennsylvania School of Medicine found that recent medical school graduates scored poorly on a musculoskeletal knowledge competency exam that had been validated by orthopedic surgeons. The study, published in the October 1998 issue of The Journal of Bone & Joint Surgery (JBJS) generated some criticism among those who believe orthopedic surgeons may not be the best group to validate the study because of their assumed emphasis toward surgical topics.

In responding to those concerns, the researchers sent the competency exam to all directors of internal medicine departments in the United States. They reported their results in the April 2002 issue of JBJS. Their rating of the test was similar to that of the orthopedic surgeons, who suggested a minimum passing score of 73%. Internists suggested a minimum passing score of 70%. Most students who took the test in the original study would also have failed according to the internists' standards.

The ratings of question importance were also similar between the two groups; however, internists placed more weight on questions that addressed fractures, back pain, arthritis, and infections.

Researchers concluded that instruction in musculoskeletal medicine, which they estimate to be an average of 2.1 weeks, is lacking, and that optimal curricular design to improve instruction would be best accomplished with the input of multiple groups of doctors so that topics important to the practice of general medicine will not be overlooked.

This Score Just In: Winter Olympic Medical Encounters

Tabulations for medical cases treated at the 2002 Winter Olympics are in and show that patients presented at venue clinics with few life-threatening conditions. The numbers were issued in a press release by Intermountain Health Care, the Salt Lake City healthcare network that handled medical care for the Winter Olympics. Among the 11,575 patients who were treated at the temporary on-site medical clinics were a few heart attacks, 16 cases of frostbite, and 43 cases of altitude sickness. The five most common medical conditions treated were respiratory infections, physical therapy needs, sprains and strains, abrasions and contusions, and eye injury or irritation. Athletes accounted for 1,377 of the medical visits.