Running Into Trouble

Attack One comes on duty at 0500 hours, and it is warm already. That’s typical for the yearly event it’s working today, a 10-kilometer summer race that draws huge crowds to watch the runners. The first race starts at 0700, so crews have to be in place at 0600 hours. This year the Attack One crew is assigned to the runners’ medical tent at the finish line. Other crews are located along the race route through the city to care for the crowds and competitors.

The race includes more than 20,000 runners, so there are always many heat-related illnesses. This year the temperature is already 73ºF., with no breeze and a relative humidity of 70%, so the rescuers and race organizers must prepare for a higher risk of heat emergencies.

The crew members arrive at the tent and meet with the combined medical crew, which includes nurses, physicians, and EMT and paramedic providers. Equipment is specially staged; it includes water-permeable cots and 30-gallon barrels filled with ice water and towels. The crews bring the usual array of cardiac monitors and emergency supplies for runners with more significant problems.

The event’s medical director addresses the group. He has been doing this event for 25 years and is himself an experienced 10K and marathon runner. “We are here to care for the runners, and we will see more than 100 this morning,” he announces. “A few will arrive with blisters, cuts or sprains, and they will be treated by the athletic staff. Most of the victims coming to this tent will be suffering from heat illnesses. They are to be cooled on the cots, rolled on their sides and observed for mental status changes. That is our key indicator of heat illness. As usual, there are no IV fluids in the tent. Unlike marathon runners, there are no indications for intravenous fluids or lines. Anyone who has a significant medical issue, like chest pain, dysrhythmia or asthma, will be placed into an ambulance and receive EMS protocol care en route to a hospital. Those things are very rare in these runners. Cooling is our priority, and we do it with ice-cold towels. When the runner can sit up and has normal mental status, they can take some oral fluids.” The directors then cover some specifics about medical record-keeping and how to get runners reunited with their families.

The senior member of the Attack One crew has participated in this event before and orients the new members to the rest of the operation. The crew will stand at the finish line of the 10K and assist in identifying runners who are in trouble as they arrive. Those runners will be guided, carried or wheeled the few yards to the medical tent, where they will be evaluated and cooled. Attack One’s paramedic member is also leading EMS triage and will assign ambulance crews to runners needing to be transported and manage any other emergencies in the crowd around the finish line.

The first runners arrive within 30 minutes of the race’s start. They are all world-class distance runners, and even they are affected by the morning’s heat and humidity. They are all medically fine, however, and move to the shaded area around the trophy area, where they will be receiving awards in a ceremony that takes place before many of the thousands of other runners even cross the finish line. After the world-class runners, who number about 20 or so, come a lot of runners who have really been running hard to catch the elite athletes. These are where the first casualties are found.

Soon the experienced “spotters” at the finish line are leading exhausted runners into the medical tent. These runners are placed on their sides on the cots, and medical personnel put ice-cold towels under their arms, across their heads and in their groins. Fans blow air across them. The runners are wearing only running shorts and shirts and shoes, so shoes are the only clothing that has to be removed. Every runner who is lucid knows they have to turn in the electronic tag on their shoes, which tracked their running time. A runner who doesn’t ask about their tag is immediately considered to have an altered level of consciousness. Accordingly, a designated member of the race team goes from patient to patient to get the tags as the shoes are removed.

The youngest member of the Attack One crew has noted the triage and screening process seems to rely on something other than traditional teaching on heat-related illnesses. “I notice these runners all come in with different-colored skin, and some are vomiting or complaining of cramps,” he says. “Some have really red skin, some are pale, some have normal skin coloring. That doesn’t seem to predict who is the sickest.”

“That’s correct, and you will see it take place the rest of the morning,” the race medical director tells him. “Mental status change is really what we have to look for. If someone isn’t thinking clearly in 10 to 15 minutes, they have a real problem and must be removed to a hospital. We have found that many runners will have cramps or throw up or complain of being hot. Most of them do just fine with about 15 minutes of cooling, then starting some oral fluids. If they don’t act right, we stay right on top of them, and if they don’t clear quickly, they go to the hospital.”

The medical staff moves the patients through very quickly. There are a few injuries—one patient with significant chest pain, one vomiting repeatedly. Dozens of runners are quickly cooled, then drink some fluids and leave the tent on their own. The sickest patients are identifiable by the number of medical staff surrounding their cots.

One young man is carried from the finish line by several of the medical staff. He is speaking incoherently, his skin is blotched, and he vomits as he’s placed on the cot. He does not react when the cold towels are put on him, and does not ask anyone to recover the tag on his shoe. He is breathing about 30 times a minute and has a pulse of about 170. His skin does not feel particularly warm. The staff rotates cold towels on him, and he doesn’t respond appropriately when asked where he’s supposed to meet family or friends. Five minutes later and again at 10, his status hasn’t changed. The medical director and Attack One paramedic are called to the side of the cot. “This young man has altered mental status and is not responding to cooling,” they’re told. “We are getting his name and medical history from the race record system. He needs to get going immediately!”

The transporting ambulance crew pulls their stretcher to the cot, loads the patient and starts to move toward their vehicle. They will transport to a hospital designated for ill runners, and do so with continued surface cooling and supplemental oxygen, and with an IV line only if they can start one en route.

An Attack One crew member accompanies the victim. The victim receives high-flow oxygen en route, but IV access can’t be obtained, and it’s difficult getting a pulse oximetry reading due to poor perfusion of the skin and no venous access. The patient’s pulse rate remains around 170, blood pressure 100/palp., and respiratory rate around 30 a minute. The 3-lead cardiac monitor shows a sinus tachycardia. The patient becomes unresponsive except to painful stimuli.

Hospital Course

The patient arrives at the emergency department, where a rectal temperature is obtained and confirms the diagnosis of severe heat illness. Despite almost 35 minutes of prehospital cooling, his temperature is 105.7ºF. Cooling in the ED is not successful, so the patient is taken to the operating room and placed on cardiac bypass, and his core temperature is cooled from 106 slowly down to 99ºF. He then goes to the ICU, where he recovers very slowly. He is released from the hospital weeks later with severe deficits.

Case Discussion

The summer months often bring major events that attract large crowds, and some of those involve athletic activities in hot weather. EMS providers may be involved in event operations for participants or crowds, and may need to screen large numbers of persons for heat-related illness. Altered level of consciousness is the single most important observation to determine what persons may have the most serious form of heat illness. This is often called heatstroke.

The risk factors for severe heat illnesses are:

• Lack of heat acclimatization. Severe heat illnesses often happen in the first few weeks to months after winter weather. By late August or September, most of the population is well-acclimatized to hot weather, and severe heat illnesses decline.

• Older age. Persons over 40, even in relatively good physical condition, have an increased potential for heat illness versus people who are under that age.

• Medications or street drugs. Many medications and a large number of illegal drugs can impact the body’s temperature-regulating systems and hydration level. Persons with these in their system are at risk for severe heat illness.

• Poor physical fitness/excessive body weight, and those who have had a previous heat-related illness.

• Dehydration.

Heatstroke results when the body’s temperature-regulating and cooling mechanisms are no longer functional. The victim has metabolic systems that begin to run out of control, and their core temperature will continue to rise. External cooling is not effective, and just relying on skin temperature will mislead caregivers.

Heatstroke victims have a high probability of permanent disability or death. The key to identifying heatstroke is altered mental status. This includes confusion, weakness, dizziness, nausea, seizures and/or headache. Do not rely on skin condition or apparent skin temperature to determine if a person is ill. Many persons who are very ill have cool, pale skin. Pulse and respiratory rates are usually elevated. Oral temperatures, and sometimes tympanic temperatures, will not reflect the elevated core temperature. Only a core temperature should be used to guide therapy. Pupils are dilated. Sometimes the victim has muscle cramps.

Customer Service

The race organizers, Attack One crew and medical team had to develop a program to reunite runners with their families. For this large event, it was necessary to develop a coordinated plan to exchange information between race organizers at the starting line, at the finish line and with the metropolitan transit authority to ensure family members could be moved to where runners ended their journeys. Large events alter many normal traffic patterns, so race organizers arranged the transit stops so family members could make their way to a hospital, the finish line or the starting line to find a runner. Runners stopping along the race route for medical reasons would be moved to the start or finish line. Area hospitals were also made aware of the transit programs and the need to have patient names available for race organizers to allow family members to come to the correct hospital.

Following the events of 9/11, many major metropolitan areas have developed plans (some with the American Red Cross) to perform family reunification at major events. Customer service training in fire/EMS departments can assist. In a major event, this is not an operation that violates patient privacy regulations.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.