Colder Weather Road Racing Events
When the fall leaves change, winter winds blow, and temperatures drop, running events don't stop for the weather. In fact, it seems more people lace up and hit the road!
From hometown Thanksgiving Turkey Trot 5K races to major city marathons such as New York City and the Marine Corps Marathon, autumn and winter weather races present unique challenges for EMS providers. Success in managing these events requires careful preparation, strategic resource deployment, and an understanding of cold-weather-specific medical concerns.
Understanding Your Event
The foundation of effective race coverage begins well before the starting gun. Event directors should provide detailed information about participant numbers, course layout, elevation changes, start/finish locations, and road closure plans. This information helps determine resource allocation, with industry standards suggesting one BLS ambulance per 300-500 participants as a baseline.
Successful event management requires coordination among multiple stakeholders. The EMS team should meet with the race director to understand event-specific concerns and expectations. Consultation with the medical director helps establish appropriate protocols for the anticipated conditions and how their requests line up with your agency, regional, or state protocols.
Local law enforcement should be contacted well in advance to assist with traffic management and security, while nearby hospitals should be briefed on the event to prepare for potential patient influx. Course volunteers represent another vital resource, and time invested in their basic medical training can prove invaluable during the event. Some larger races, such as the New York City Marathon, have thousands of race-day medical volunteers from EMTs to physical therapists to physicians.
Strategic Resource Deployment
Effective positioning of medical resources can dramatically impact response times and patient outcomes. The primary medical tent should be positioned at the finish line, equipped with heating systems and staffed with appropriate medical personnel.
Depending on course layout, distance, and participant numbers, satellite treatment areas along the course provide additional support, particularly in areas with challenging access. Clearly for a 5K this level of care won’t be needed, but for a 10-miler, half or full marathon, it will be a necessity.
Rather than having ambulances follow the last runners at three miles per hour, establish strategic staging zones with clear egress routes. These positions should account for road closures and anticipated traffic patterns. Consider having either regular intervals of AED stations throughout the course or having highly mobile EMS teams with AEDs, such as on bicycles, gators, ASAPs, or motorcycles, that can easily and quickly get through congested areas. quick response or strike teams equipped with AEDs and trauma bags can respond quickly to emergencies.
Additional support services play a crucial role in event coverage. Ham radio operators can provide additional communication coverage, especially in areas with challenging terrain or limited cellular service. The fire department may assist with both medical support and logistics, while police manage traffic control and course security. Even public works or sanitation will be helpful with race barricades or blocking traffic with large vehicles.
Essential Equipment
Colder weather events demand specialized equipment beyond standard EMS supplies. Temperature management becomes critical, requiring portable heaters, bulk supplies of thermal blankets, hot packs, and warm beverages. Heated treatment areas should be established in medical tents, providing shelter from wind and precipitation.
Medical supplies should include multiple AEDs, MCI triage materials, and standard trauma supplies. The shorter daylight hours of winter races necessitate adequate lighting for treatment areas, along with reflective gear for medical staff. Clear signage helps participants and spectators locate medical assistance quickly when needed.
Don’t forget to keep your personnel warm too! Runners get warm by running. EMS personnel at the race should have hats, gloves, insulated jackets, and layers!
Common Medical Emergencies
Cold weather races present unique medical challenges. Hypothermia remains a primary concern, manifesting through shivering, confusion, and slurred speech. Treatment protocols should emphasize removing wet clothing, applying passive rewarming techniques, and using heated blankets while monitoring core temperature.
Cardiac events pose increased risks during cold weather, demanding immediate access to AEDs and clear protocols for cold-induced respiratory and chest pain management. Cold muscles prove more susceptible to strains and tears, while icy conditions can lead to falls requiring traditional immobilization and pain management protocols.
Exercise-associated collapse, particularly common at finish lines, requires specific management strategies. Proper patient vital sign monitoring and rewarming measures form the foundation of treatment. Despite cold conditions, dehydration remains a significant concern as participants may skip fluid stations due to reduced thirst sensation as a result of colder weather.
Recent Research Findings
Recent studies have enhanced our understanding of race-related medical care. Research published in the Journal of Sports Medicine identified miles 18-22 as critical zones for cardiac events during cold weather marathons, suggesting strategic proactive placement of AED stations and medical personnel in these areas.1
A comprehensive study in Wilderness & Environmental Medicine found that runners maintaining 3:45-4:30 marathon paces showed the highest risk for hypothermia in sub-40°F conditions.2 This finding helps medical teams identify at-risk participants before symptoms become severe.
Analysis of major marathons demonstrated that immediate leg elevation combined with passive rewarming reduced hospital transport rates by 45% for exercise-associated collapse in cold weather races, supporting the efficiency of on-site treatment protocols.3
Hydration research confirmed that cold weather runners require 4-6 oz of fluid every 15-20 minutes, despite reduced thirst sensation, emphasizing the importance of regular aid station monitoring by medical personnel.4
A large-scale review of cold weather races revealed that pre-positioning medical teams based on historical injury data reduced response times by 37% compared to traditional equidistant spacing.5 This finding supports the value of analyzing past race event data when planning medical coverage.
The Journal of Emergency Medical Services published findings showing that medical tents utilizing forced-air warming systems reduced the average treatment time for hypothermic runners by 23 minutes compared to traditional passive warming methods, suggesting the value of investing in active warming equipment for cold weather events.6
Common Running Injuries
Injuries at shorter road races tend to be rare, as most participants have safely trained and are prepared for the race. Longer races such as half and full marathons tend to have more overuse injuries. Regardless, these are the more common injuries to see in runners:
Blisters. Due to brand new running shoes, cotton socks that rub, or shoes that don’t fit, runners often get friction blisters that can be painful or even bleed on their toes and feet. Lancing a blister is outside of EMS scope in most cases, so cleaning the blister and applying a bandage are best bets for treatment.
Sprain or fracture. A wrong step, a trip over a curb, or an inadvertent contact with another runner can cause orthopedic injuries to the extremities for runners. Follow your agencies’ protocols for suspected fracture management, which commonly includes ice, immobilization, transport to a facility, and possible pain relief.
Dehydration. If a patient is presenting with extreme thirst, altered mental status, agitation, or elevated body temperature, consider dehydration as a cause. You would assess a patient as you normally would, but be aware of dry mucous membranes, sunken eyes, poor skin turgor, hypotension, and slow capillary refill. In addition to airway-breathing-circulation support, consider ALS interventions for IV rehydration.
Hypoglycemia. If a runner has gone longer distances and hasn’t fueled correctly, they might be hypoglycemic. They might present with nausea, confusion, or altered mental status. Assess and support airway-breathing-circulation and take a glucometer reading. If they are conscious, consider oral glucose and/or IV access and either glucagon or D50 administration, depending upon your local protocols.
Syncope. Syncope can occur for a variety of reasons, especially in a running race. Over-exertion, hypo- or hyperthermia, cardiac abnormalities, or simply exercise-associated collapse can cause syncope.
If the patient has no pulse, begin CPR and attach an AED as soon as possible. (Consider training course volunteers in hands-only CPR prior to the event and pre-positioning AEDs on the course). Exercise-associated collapse can occur, especially at longer distance events such as half marathons and marathons when blood pools in the lower extremities and the runner comes to a standing halt after running for several hours. Initial treatment in all cases is to monitor and control the airway, breathing, and circulation. Additional supports can include raising the legs, warming/cooling, hydration, and cardiac monitoring.
Upset stomach. Running can be a cause for an upset stomach. Whether it is anxiety about the race, consuming not enough or the wrong kind of race nutrition, colon motility due to running (aka “runner’s trots”, or dehydration (see above), many competitors present with abdominal pain or discomfort. Assess the patient, ensure that ABCs are stable, and place the patient in a position of comfort. Keep an emesis bag nearby. If protocols and training allow, consider administration of ondansetron, IV rehydration, or consulting medical control.
With the proper pre-planning and logistics, EMS agencies can ensure that all athletes can have a safe and fun race day as they complete their miles to meet their goals!
References
- Johnson M, et al. (2023). Temporal distribution of cardiac events in cold weather marathons. Journal of Sports Medicine, 52(8), 1456-1470.
- Martinez C, & Lee K. (2022). Hypothermia risk assessment in marathon runners. Wilderness & Environmental Medicine, 33(3), 289-301.
- Thompson R, et al. (2021). Treatment protocols for exercise-associated collapse in cold weather races. International Journal of Sports Medicine, 42(6), 523-537.
- Williams P, et al. (2020). Hydration strategies for cold weather endurance events. Medicine & Science in Sports & Exercise, 52(11), 2345-2358.
- Anderson K, & Smith, J. (2024). Optimizing medical team positioning in cold weather endurance events: A data-driven approach. Sports Medicine Journal, 45(2), 112-128.
- Garcia R, et al. (2023). Comparative analysis of warming techniques in race medicine. Journal of Emergency Medical Services, 48(4), 78-92.
Barry Bachenheimer, EdD, NREMT/FF is a runner, active EMS provider, member of marathon medical teams, and frequent contributor to EMS World. This article was updated in 2024 from its original 2018 version.
