12 May 2014

Fall weekend – ultramarathon injuries and medical care in remote environments

The past week it has felt like fall in Uppsala with freezing temperatures in the mornings and peak temperatures in the afternoons in the high 40’s (around 10°C). The spring has not completely stalled, however, just slowed down and it is becoming really green after all rains. I do not know if it is the weather, but I have felt quite tired the past week and it has reflected my training were I have fallen back to slower distance training runs.

The reason for the name of this post is however not the fall-like weather. Last Friday lunch I was out for the first real speed training Fartlek of around 15 km (10 miles) for a week. I was running on a rather technical trail along the local lake Mälaren, a wonderful path leading to hidden beaches and a normal spring day you would encounter both walkers and cyclists here, however, due to the pouring train I was running completely alone this day. I also frequently left the normal path, venturing out in the woods quite often to gain more elevation. It was real life quality and as it felt really great and I was really inspired I found myself gradually increasing my speed during my rushes - until I suddenly fell headlong with really strong force. When I lay gasping for my breath, as I had landed mostly on my chest, in a puddle of water I realized I had stepped on one of my shoelaces as an amateur. Luckily, I fell in an uphill section and landed rather softly and did not sustain any serious injuries.  It was however quite an humbling experience and, as my Iphone 5 once again had stopped working due to the cold and rain, I realized I would probably have been lying for quite some time before I was found if I had been severely injured. Certainly not like Aron Lee Ralston, but two take-home lessons from this episode are anyway: 1) always bring a functioning weather resistant mobile; and 2) let someone know where I am going running.
Running alone in the rain along the Lake Mälaren
I was also reminded about the risks of traumatic falls during trail running following Transvulcania at Irunfar this weekend and noticing Emelie Forsberg sustaining a rather severe fall requiring hand stitches and surgery. The medical care seemed to have worked excellently, as I think is the case for most races nowadays. I was really impressed by the medical care, even though I myself declined any despite the best interest of at least my feet, at Tor des Geants last year. A guideline for medical care services at ultra-endurance foot races was just published in Sports Medicine (Hoffman et al “Medical services at ultra-endurance foot races in remote environments:  medical issues and consensus guidelines” Sports Med 2014; Epub ahead of print). It is an excellent review of what the medical organization at a mountain ultramarathon might encounter and it sets the minimum standards for what a race organization should provide. The minimum level of medical services that each event should have in place is according to the article a plan for emergency transport of injured or ill participants, pacers, spectators, and event personnel to local hospitals or medical facilities.

Emelie Forsberg having sustained a hand injury at Transvulcania 2014. Picture from Irunfar
Most race organizations today, however, are expected to provide more comprehensive level of medical support and care and the article about Hoffman and colleagues discusses some of the legal and organizational ramifications with this. Paradoxically, having medical support at a race might expose the race organization and the medical personnel to litigation as no waiver advising participants of risks and their assumption of those risks absolve from responsibility for gross negligence and the definition of this is most often determined through a litigation process. There is currently a debate ongoing about this in Sweden and the advice from for instance the Swedish Medical Association to all Swedish physicians is actually to not provide health care at an event unless you are willing to assume full legal responsibility as a care giver. This is a major issue and the Swedish Ministry of Health and Social Affairs is therefore actually currently investigating how the laws could be changed to more readily enable physicians and other licensed health care professionals to give care during sports events. Good Samaritian-type legislation is clearly not providing protection for volunteer athletic events in either Sweden or other countries such as the US (Ross et al “Action in the event tent! Medical legal issues facing the volunteer event physician” Sports Health 2013; 5. 340-345).

On a smaller personal level for me as a physician this creates some uncertainties and thoughts about what I for instance should bring for the first aid medical kit at Petite Trotte à Léon in the form of equipment and medication. Should I bring epinephrine and other medicines and a laryngeal mask or endotracheal tubes for cardiopulmonary resuscitation? Medicines and equipment for wound stitching? Where is the border between giving care for an acute life threatening condition and to give general medical care? Regardless of the legal ramifications I am probably aiming to bring enough equipment so that I can take care of most acute situations that my teammate Otto and myself can encounter between the aid stations. And, to have a telephone working in rain and cold.  


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