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Inside the Medical Tent at the Boston Marathon
Hot, Windy 2004 Race Prompts New Safeguards

The Boston Marathon is in a league of its own as an American sports icon. The race course starts on the town green of a small rural village and then spills through bigger towns until it reaches the finish line in downtown Boston. The race is always held at noon on Patriot's Day on the third Monday of April, and the Boston Red Sox usually play an 11 am game that day to allow fans at Fenway Park to cheer on the runners. This year, the Red Sox play the Toronto Blue Jays.

Healthcare professionals who have an interest in covering marathons often look to the Boston event, the oldest and largest of its kind in the United States, for guidance and inspiration. So when 87°F temperatures at the 2004 race nearly overwhelmed the medical system, the medical community took notice, hoping to learn from challenges the medical team faced and the adaptations planned for this year's race.

Nearly a Mass Casualty Event

Chris Troyanos, ATC, an athletic trainer at Sports Medicine Consultants in Boston, is a medical coordinator of the Boston Marathon and has worked with the marathon for 27 years. He says medical volunteers have come to expect wide temperature variations from year to year; occasionally, there's even snow. "Boston normally doesn't get hot that time of year, and we normally treat hypothermia," he says.

There have been hotter years; the 1976 marathon recorded temperatures of 96°F and was nicknamed the "run for the hoses." In 1987, temperatures climbed to the mid 80s with more than 95% humidity. What happened in 2004 was unique, however, because the number of participants was much higher than in the past—nearly 20,000 runners ran the race. Troyanos says that the number of athletes treated at the finish line during a typical busy race day is 600; however, in 2004 the medical team treated 1,100 runners. In a normal year, 20 or 30 runners end up being transported from the course to the emergency department, but in 2004, Troyanos and his team saw that number rise to 170.

Officials at the Boston Athletic Association (BAA), the organization that runs the Boston Marathon, knew a week ahead of time that race day could be hot. "We talk every day, because the weather changes here are dramatic and quick," he says. Extra medical staff, supplies, and equipment were deployed, and two extra medical tents were set up. "Hurricane-force wind gusts of 60 mph came through, and we had to shut the second and third medical tents down. The wind was moving the tents and flinging the cots around," Troyanos says.

At the starting line, officials used the public address system to warn runners about the dangers of the heat and advised them to slow down and hydrate normally. Extra water was handed out on the course. The BAA also doubled the interval allotted to timing and scoring to allow as many runners as possible to be officially recorded, receive a medal, and appear in the record book. According to the BAA, 93% of the runners finished the race.

"We knew we were going to be overwhelmed, and it was like a wave," Troyanos says, noting that runners waited in lines to seek treatment in the medical tent. "It really taxed us, and some of our contingency plans failed. But we bent—we didn't break." Emergency medical service task forces were called in at the last minute to follow groups of runners and transport the collapsed participants to local hospitals.

Marvin Adner, MD, medical director for the Boston Marathon, points out that the low humidity that day, combined with the heat, contributed to volume depletion in many runners who sought care in the medical tent. "We started 172 IVs that day—the most we've ever had," says Adner, who is director of hematology at MetroWest Medical Center in Framingham, Massachusetts.

Despite the high numbers of athletes who needed acute care, Troyanos says there were relatively few life-threatening incidents. "There were three or four severe cases of hyponatremia plus two more that our staff never saw," he says.

Experiences Prompt Changes

The number of emergency transports for runners who collapsed on the course that day overwhelmed local emergency departments, which could have created a public safety concern, Troyanos says. To better enable the medical team to respond on the course, the BAA is working with the local disaster management assistance teams (DMATs) to set up "mini emergency departments" on the course. These supplement the 26 Red Cross first aid stations that traditionally dot the course. "Physicians will be staffing these DMAT stations, and they'll be able to start IVs and check sodium levels," he says. The DMAT stations will help the medical team accomplish one of its most important goals, Troyanos says: responding to any down runner on the course.

Adner says that the medical facilities were not geared for what unfolded that day. As a result, the Massachusetts Department of Public Health has become involved in medical planning for the marathon. The department's role will be to facilitate communication between the marathon medical team, local hospitals, and the municipalities that are on the marathon route. Troyanos says: "They bring a tremendous support and guidance, and their involvement gives us more clout, and people sit up and take notice."

Education is another step in making sure medical staff and runners are better prepared. Volunteers need to be better aware of the medical team's goals and protocols, Troyanos says, and hospital staffs need to know more about the conditions they are likely to see, such as hyponatremia.

Track Record Weathers Changes

Key members of the Boston Marathon's core medical team have served 25 years together and, aside from Troyanos and Adner, include Joan Casey, RN, a critical care nurse who serves as a medical coordinator, and Kathryn Brinsfield, MD, MPH, an emergency medicine.

Adner, who has a personal interest in marathoning and was instrumental in starting the medical team in 1978, says the medical issues have grown substantially more complex at marathons, particularly in the last 15 years. "I used to run the race until about 1990, delegating much of the work to Joan Casey, but the medical responsibilities have gotten so big that I spend more time organizing," he says. Staffing needs for medical care have grown from just a handful of medical professionals in the late 1970s to a medical team of about 1,300 volunteers for the most recent marathon.

In the medical team's early days, there were few serious incidents other than heatstroke, dehydration, and occasional cardiac arrests. Adner says the emergence of hyponatremia at road races represents a major shift that may relate to the changing characteristics of some runners who participate in marathons. He notes that the running population is less elitist and runs marathons not just for purely competitive reasons, but also for charity or enjoyment. As such, some participants have slower race times and have more opportunities on the course to hydrate, which can lead to the overhydration that can cause hyponatremia.

On a lighter note, another trend that Adner and the medical team have seen change is the thinking behind the postrace meal, which for many years was always a heavy Irish-style beef and potato stew. "It was greasy and impossible to digest after the race," Adner says. Now the participants get lighter fare such as corn chips, cola, and yogurt to help provide the sugar, fat, and protein needed for exercise recovery.

And what about the famous prerace pasta dinner? "It's still valid. It's good for water loading and glycogen loading," Adner says.

Lisa Schnirring

Field Notes

Exercise Confers Health Benefits During Menopause

Physical activity provides important health benefits during menopause, according to German researchers who reported their 3-year findings in the February issue of Medicine & Science in Sports & Exercise.

Study participants included 78 women ages 52 to 58 who were in early menopause and demonstrated signs of calcium loss at the spine and hip. The women were without any medication or illness that affected bone metabolism. The 48 women who were assigned to the exercise group performed four weekly exercise sessions—two supervised and two at home. Their routine consisted of low- and high-impact aerobics and rope skipping for endurance, plus jumping and dynamic and isometric exercises for strength. The control group included 30 women. Both groups took calcium and vitamin D supplements and kept diet logs.

At the end of the 38-month study, researchers found that the exercise group improved in all areas that were measured:
• Bone mineral density (BMD) stabilized, whereas the control group's BMD was severely reduced;
• Total cholesterol and triglycerides decreased but increased in the control group;
• Waist circumference decreased but stayed the same in the control group;
• Isometric and dynamic muscle strength increased, while that of the control group decreased slightly;
• Endurance and aerobic capacity increased, whereas the control group's decreased; and
• Menopausal symptoms such as insomnia, migraines, and mood changes were modestly reduced, but there were no changes in hot flashes or depression.

The researchers concluded that a mixed, high-intensity exercise program compensates for most negative changes related to menopause, and that the changes can be maintained for at least 3 years. In a press release from the American College of Sports Medicine, Wolfgang Kemmler, PhD, lead researcher for the study, said "Participants who kept up the exercise regimen showed lasting benefits for heart and bone health, as well as increased strength and an easing of the symptoms of menopause. These results point the way to health and fitness improvements that are available to all women."

Low-Carb Diets: Why the Quick Results?

The popularity of low-carb diets has been fueled by the speedy weight loss that dieters experience, and healthcare professionals have wondered what causes such results. Some experts have attributed some of the effects to water loss, metabolism, or boredom; however, a new study from Temple University School of Medicine suggests that dieters spontaneously avoid increasing their consumption of proteins and fats when they reduce their intake of carbohydrates.

The study, published in the March 15 issue of Annals of Internal Medicine, involved 10 obese patients who had type 2 diabetes. The participants consumed their usual diets for the first 7 days of the study, then followed the low-carbohydrate Atkins diet for 14 days. (The subjects' diet limited carbohydrate to 20 g per day with unlimited protein and fat intake.) Researchers monitored subjects' body weight, water, and composition; energy intake and expenditure; diet satisfaction; hemoglobin A1c; insulin sensitivity; 24-hour urinary ketone excretion; and plasma profiles of glucose, insulin, leptin, and ghrelin.

At the end of the study, conducted in the clinical research center of the university hospital, researchers found that when subjects were on the low-carbohydrate diet, mean calorie consumption decreased from 3,111 kcal/day to 2,164 kcal/day. The calorie deficit produced a 1.65-kg weight loss in the 14 days that subjects were on the low-carbohydrate diet. Mean 24-hour plasma levels normalized, mean hemoglobin A1c decreased from 7.3% to 6.8%, and insulin sensitivity decreased by about 75%. Mean plasma triglyceride and cholesterol levels also decreased.

Though the study was limited by short duration, a small study group, and lack of a strict control group, researchers concluded that subjects, on their own, reduced carbohydrates without increasing their intake of other foods. Lead researcher Guenther Boden, MD, in a press release from Temple University School of Medicine, said, "They weren't bored with the food choices. In fact, they loved the diet. The carbohydrates were clearly stimulating their excessive appetites." Boden added that the long-term effects of low-carbohydrates are not known, and that research is needed to investigate if other types of diets have similar effects.