Triathlon Race Day Medical Care

Hiller, W. D. B.

doi:10.1007/978-3-030-22357-1_22

W. D. B. Hiller^2,3,4

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Abstract

Triathlon is a sequential swim/bike/run race. As such, the sport poses unique challenges for the medical care of the athletes.

Planning for and treating the potential medical problems encountered in an open water swim, bicycle race, and distance run require a detailed knowledge and attention to each part of the race.

Pre-race organization is the foundation for success. The physician in charge of directing medical care must be an integral part of the Race Committee and race planning procedure. This should include involvement in the race course design.

Ambulance access to the course, water quality, water and air temperature monitoring, as well as safety issues for each leg of the course requires attention. Explicit planning for mass casualties in the event of natural disaster or attack should be detailed. Cooperating hospitals and ambulance services must be identified early on.

Medical staffing, logistics, and medical supplies are a sine qua non for success on race day.

Medical access to the race course must be safe without interfering with the race. Medical assessment and care at the finish line requires careful coordination, and education for the medical and finish line personnel.

There must be clear and unobstructed access to the medical tent from the finish line, and for ambulances from the street.

Communication among medical personnel at the main medical tent and in hospitals is essential. There should be a plan to communicate with families or friends of injured athletes.

Successfully planning and executing the medical coverage for hundreds or thousands of athletes can be a daunting challenge. The recipe for success is polite, relentless pursuit of the best care for our athletes.

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Authors and Affiliations

Elson S. Floyd College of Medicine, Washington State University, Pullman, WA, USA
W. D. B. Hiller
John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
W. D. B. Hiller
Whitman Hospital and Medical Center, Colfax, WA, USA
W. D. B. Hiller

Authors

W. D. B. Hiller
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Editors and Affiliations

International Triathlon Union ITU, Medical Committee Maison du Sport International, Lausanne, Switzerland
Sergio Migliorini

Appendices

Appendix 1

Medical and anti-doping control management in ITU event. ITU competition rules 2019.

1.1 Medical and Anti-doping Control Management in ITU Event

1.1.1 Medical Management

1.
General
1. (a)
  The ITU Medical Committee may appoint a medical delegate to oversee the medical operations of the event.
2. (b)
  The ITU Medical Delegate (ITU MD) may conduct one site visit prior to an ITU event.
3. (c)
  The ITU Medical Delegate will liaise with the event appointed RMD. The ITU Medical Delegate reviews, with the RMD all the information relating to medical and doping control requirements for the event.
4. (d)
  The RMD attends the ITU event, the year prior to study and work with the medical team.
2.
Medical plan

The LOCs of the World Championship, World Cup, and Continental Championship events should submit a full competition medical plan to the ITU Events Department and to the ITU Medical Committee no later than 1 month before their event. This document should include:
1. (a)
  Onsite medical services (facilities, equipment, and supplies).
2. (b)
  Offsite medical services (facilities, equipment, and supplies).
3. (c)
  Medical coverage per discipline.
4. (d)
  Paratriathlon special services (if applicable).
5. (e)
  Staffing and scheduling.
6. (f)
  Ambulance distribution and medical response maps.
7. (g)
  Communication plan.
8. (h)
  Operational plan and procedures.
9. (i)
  Team doctors Information and registration forms.
10. (j)
  Athletes’ waiver.
11. (k)
  Budget.
3.
Personnel
1. (a)
  The LOC will appoint a RMD. The RMD is responsible for the overall medical operations of the venue, and should preferably have experience in major sport/endurance events. The RMD is responsible for informing the ITU Medical Delegate (ITU MD) and/or TD about the medical organization of the event.
2. (b)
  The RMD appoints other medical staff; organizes the facilities in cooperation with the LOC; and organizes supplies and equipment.
3. (c)
  Two paramedics per 100 athletes is the minimum.
4. (d)
  There should be 1 physician per 200 athletes with a minimum of 4 physicians.
5. (e)
  There should be 1 nurse per 100 athletes with a minimum of 6 nurses.
6. (f)
  Two doctors must be present and on duty for the entire event. One doctor should be located within the medical facility and the other doctor must be mobile.
7. (g)
  Physicians have the authority to withdraw an athlete at any point for safety or health reasons.
8. (h)
  Doctors, nurses, and paramedics must be clearly identifiable and have the authority to enter the field of play in the event of medical emergencies.
9. (i)
  Medical spotters will be placed along the swim course.
10. (j)
  Medical spotters will be placed every 500 m on the bike course and will be supplied with radios and/or cell phones. The spotters will not be on the field of play, but will have access in the case of an emergency.
11. (k)
  Medical spotters will be placed on the run course (numbers will be determined based on the course design).
12. (l)
  Paramedics and stretchers must be in attendance adjacent to the swim exit, transition area, and at the finish area.
13. (m)
  The LOC must ensure that all marshals and other race officials are aware of all medical facilities and their locations.
4.
Ambulances and access
1. (a)
  A minimum of three ambulances will be required, plus an additional one for every 500 athletes: one ambulance will be stationed near the finish area and the medical facility, two ambulances will be stationed strategically on the bike course. The final number should be approved by the ITU MD or TD.
2. (b)
  Ambulances will be equipped with the following: direct communication with medical headquarters and direct communication with all necessary cardiopulmonary resuscitation supplies and trained personnel.
3. (c)
  Ambulance emergency access routes must be planned both from the competition site and bike course.
5.
Hospitals
1. (a)
  The nearest hospital must be informed of the event well in advance and advised of the possible emergency that may arise.
6.
Medical records
1. (a)
  Accurate and complete medical records must be kept on all medical instances. Those records must be submitted to the ITU Medical Delegate or TD.
2. (b)
  The records must be shredded after the events to protect the privacy laws in place in each jurisdiction.
7.
Race medical management
1. (a)
  Main principles for an effective race medical management.
  - Split the course in sectors in order to have the same communication code between the TOs, medical staff, and LOC.
  - Place the ambulance at the most dangerous points.
  - Make sure that an ambulance can reach the entire field of play using the minimum of the course.
  - Allocate a number to the dangerous corners for effective communication.
  - Make sure that there will be a number of paramedic bikes for an effective response to the accidents.
  - The volunteers that are found in distance of 100 m from the point of the accident should make warning signals to the following athletes.
  - Report to the VCC immediately.
  - Inform the TD and the medical services.
  - The ambulance should enter from the nearest intersection and park close to the side of the road. The volunteers should continue to inform the other athletes.
  - The ambulance should exit from the nearest crossing point. The ambulance should move on the FOP according to the athletes’ flows.
  - When there is a need for a simple transport of a patient from the spot of the incident to the venue, then the ambulance may follow the course to the athletes’ area. In case of an accident of involving many athletes during the bike course, we should ensure first the athletes’ integrity who is involved in the accident as well as the other athletes, and those needing medical attention will be sent to the nearest medical services. The actual facility is arranged prior to the event by the ITU Medical Delegate or TD.
8.
Athlete medical
1. (a)
  Area specifications.
  - Finish area tent size: 3 × 6 m for World Cup/9 × 9 m for World Championships.
  - Location of tent: adjacent and accessible to finish area.
  - Four tables.
  - Twelve to twenty chairs.
  - Two wheel chairs.
  - One carry chair.
  - Six stretchers.
  - Access to toilets.
  - Radio communication and medical records area.
  - Must be located in a secure area with direct access to the competition finish and must not be accessible to media.
  - Emergency access and ambulance placement must be planned.
9.
Medical supplies
- Cardiopulmonary resuscitation.
- Medication for acute cardiac care, asthma, and allergy.
- ECG machine 12 leads.
- Defibrillator.
- Blood glucose monitoring equipment.
- Sodium level analyzers.
- Oxygen.
- Thermometers and rectal thermometers.
- IV fluids (NS or 5% dextrose in NS, 3% Nacl).
- Ice, ice buckets, and ice water tubs.
- Blankets.
- Towels.
- Dressing material wound care.
- Hospital to be notified.
- Medical emergency vehicles on site and on course with planned access routes.
- Bikes for mobile medical spotters.
- Medical records (all medical treatments must be recorded and stores for records).
- LOC must ensure that all athletes sign the medical waiver and report any allergies or medications that are being taken.
10.
Massage facilities
1. (a)
  General requirements.
  - A massage facility should be placed adjacent to the athletes lounge, but not in the medical facility area.
  - The massage facility should be available at tent or other such covered facility.
  - Massage personnel should be determined by the number of athletes and the level of services offered.
  - Massage is not a requirement, but is recommended as a service to the athletes.
11.
Spectator medical
1. (a)
  10-m² tent should be provided for spectator medical personnel with limited facilities as above.
12.
Cold water conditions’ preparation

It is often organized in events where water temperature below 15 °C. Although the final distance of the swim leg is a decision that has to be made by the TD, the ITU Medical Delegate, the LOC Medical Team, and the Lifeguards, the LOC should provide the following in any case:
1. (a)
  Shower with ambient water temperature at the swim exit.
2. (b)
  Advise the athletes to have a proper swim warm-up in order to immerse their bodies and heads prior to starting the competition to acclimatize.
3. (c)
  Blankets, and so on to combat hypothermia should be ready.
4. (d)
  Increase the number of the safety boats and equip them with space blankets.
5. (e)
  Create medical stations around the course where athletes with hypothermic symptoms can stop.
6. (f)
  Provide heaters and blankets at the recovery area.

1.1.2 Doping Control

1.
General
1. (a)
  It is the responsibility of the LOC to make sure that anti-doping control is conducted at the event. The LOC should contact the proper anti-doping organization and arrange for the appropriate number of tests to be conducted. The number of tests needed will be stated in the contract. A minimum of 10 urine tests should be conducted at any ITU event.
2. (b)
  ITU complies with WADA on all doping rules and regulations (See ITU website for all current information on anti-doping control). All tests should be conducted using best practices of all international standards.
3. (c)
  The results of all tests and the anti-doping control forms should be forwarded to ITU as soon as possible.
4. (d)
  Provisions should be made to accommodate anti-doping control at the event. This will include at a minimum private waiting areas, secure washroom facilities, processing rooms, and bottled water.
2.
Personnel
1. (a)
  The anti-doping control agency will require a number of doping control chaperones. The exact number will depend on the number of tests being completed and the event schedule. Both male and female chaperones will be needed. In some countries, the national federation may have certain obligations to the national anti-doping agency, please check with your NF on this issue.
3.
Doping control
1. (a)
  The LOC of each ITU event must have provisions for a minimum of 10 in-competition urine tests. The exact number and who will be tested will be communicated to the TD by the anti-doping organization conducting the tests.
2. (b)
  The LOC must contact the anti-doping organization associated with the national federation in their country or region. If you are unsure, please contact ITU Anti-Doping Director for an agency in your area.
3. (c)
  Once doping control has been confirmed with the appropriate agency, please inform the ITU Anti-Doping Director.
4. (d)
  Anti-doping control facility onsite requirements: the exact size will be determined by the number and type of tests being conducted. The anti-doping organization conducting the tests will be able to specify exactly what requirements they will need to have to conduct the tests according to the international standards of testing:
  - A 3 × 3 m area (preferably not a tent) completely private area, away from the public and media.
  - Two double toilets to accommodate the testing procedure.
  - Two tables.
  - Twelve chairs.
  - Bottled water, sport drink, and replenishing food for the athletes (sealed).
  - Minimum of 10 volunteers to work as drug testing chaperones.
  - Security personnel to ensure that only doping control personnel and athletes, with their designated personnel, are allowed in the anti-doping control area.

Appendix 2

ITU swimming: general rules, wetsuit use, modifications. ITU competition rules 2019.

1.1 Swimming ITU Competition Rules

1.
General rules
1. (a)
  Athletes may use any stroke to propel themselves through the water. They may also tread water or float. Athletes are allowed to push off the ground at the beginning and the end of every swim lap.
2. (b)
  Athletes must follow the prescribed swim course.
3. (c)
  Athletes may stand on the bottom or rest by holding an inanimate object, such as a buoy or stationary boat.
4. (d)
  In an emergency, an athlete should raise an arm overhead and call for assistance. Once official assistance is rendered, the athlete must retire from the competition.
5. (e)
  Athletes may sportingly maintain their own space in the water:
  - Where athletes make accidental contact in the swim and then immediately afterwards move apart with no penalty incurred.
  - Where athletes make contact in the swim, and an athlete continues to impede the progress of the other athlete without moving apart, this action will result in a time penalty.
  - Where athletes deliberately target another athlete to impede their progress, gain unfair advantage and potentially cause harm will result in disqualification and may be reported to World Triathlon Tribunal for potential suspension or expulsion.
6. (f)
  Rules about water quality are outlined in Section 11.

2.

Wetsuit use

(a)
Wetsuit use is governed by the following tables:

Elite, U23, junior and youth athletes:
Swim length	Forbidden	Mandatory^a
Up to 1500 m	20 °C and above	15.9 °C and below
1501 m and longer	22 °C and above	15.9 °C and below
Age group athletes
Up to 1500 m	22 °C and above	15.9 °C and below
1501 m and longer	24.6 °C and above	15.9 °C and below

^aWhen mandatory, the wetsuit must cover at least the torso

3.

Maximum stay in water

Swim length	Elite, U23, junior and youth	Age group
Up to 300 m	10 min	20 min
301–750 m, below 31 °C	20 min	30 min
301–750 m, 31 °C and above	20 min	20 min
751–1500 m	30 min	1 h 10 min
1501–3000 m	1 h 15 min	1 h 40 min
3001–4000 m	1 h 45 min	2 h 15 min

4.

Modifications

(a)
The swim distance can be shortened or even cancelled according to this table.

Original swim distance	Above 33.0 °C	32.9– 32.0 °C	31.9– 31.0 °C	30.9– 15.0 °C	14.9– 14.0 °C	13.9– 13.0 °C	12.9– 12.0 °C	Below 12.0 °C
Up to 300 m	Cancel	Original distance	Original distance	Original distance	Original distance	Original distance	Original distance	Cancel
750 m	Cancel	Cancel	750 m	750 m	750 m	750 m	750 m	Cancel
1000 m	Cancel	Cancel	750 m	1000 m	1000 m	1000 m	750 m	Cancel
1500 m	Cancel	Cancel	750 m	1500 m	1500 m	1500 m	750 m	Cancel
1900 m	Cancel	Cancel	750 m	1900 m	1900 m	1500 m	750 m	Cancel
2000 m	Cancel	Cancel	750 m	2000 m	2000 m	1500 m	750 m	Cancel
2500 m	Cancel	Cancel	750 m	2500 m	2500 m	1500 m	750 m	Cancel
3000 m	Cancel	Cancel	750 m	3000 m	3000 m	1500 m	750 m	Cancel
3800 m	Cancel	Cancel	750 m	3800 m	3000 m	1500 m	750 m	Cancel
4000 m	Cancel	Cancel	750 m	4000 m	3000 m	1500 m	750 m	Cancel

Note: the temperatures above are not always the water temperature used in the final decision. If the water temperature is at or below 22 °C and the air temperature is at or below 15 °C, then the adjusted value is to decrease the measured water temperature according to the next chart:

		Air temperature (value in °C)
		15	14	13	12	11	10	9	8	7	6	5
Water temperature (value in °C)	22	18.5	18.0	17.5	17.0	16.5	16.0	15.5	15	14.5	14.0	Cancel
	21	18.0	17.5	17.0	16.5	16.0	15.5	15.0	14.5	14.0	13.5	Cancel
	20	17.5	17.0	16.5	16.0	15.5	15.0	14.5	14.0	13.5	13.0	Cancel
	19	17.0	16.5	16.0	15.5	15.0	14.5	14.0	13.5	13.0	12.5	Cancel
	18	16.5	16.0	15.5	15.0	14.5	14.0	13.5	13.0	12.5	12.0	Cancel
	17	16.0	15.5	15.0	14.5	14.0	13.5	13.0	12.5	12.0	Cancel	Cancel
	16	15.5	15.0	14.5	14.0	13.5	13.0	12.5	12.0	Cancel	Cancel	Cancel
	15	15.0	14.5	14.0	13.5	13.0	12.5	12.0	Cancel	Cancel	Cancel	Cancel
	14	14.0	14.0	13.5	13.0	12.5	12.0	Cancel	Cancel	Cancel	Cancel	Cancel
	13	13,0	13.0	13.0	12.5	12.0	Cancel	Cancel	Cancel	Cancel	Cancel	Cancel

(b)
If other weather conditions dictate, that is, high winds, heavy rain, changing temperature, current, and so on, the Technical Delegate in consultation with the Medical Delegate (if applicable) may adapt limits of the swim length or adopt provisions about the use of wetsuits. The final decision will be made 1 h before the start and will be clearly communicated to the athletes by the Technical Delegate;
(c)
For aquathlon events (normally run-swim-run), the LOC should plan for a swim-run where the water temperature is expected to be below 22 °C. Where a run-swim-run aquathlon has been planned, but on competition day the water temperature is below 22 °C, the format will change to swim-run;
(d)
Water temperature must be taken 1 h prior to the start of the event on competition day. It must be taken at the middle of the course and in two other areas on the swim course, at a depth of 60 cm. Where the average measured figure is 27 °C or below, the lowest measured temperature will be considered as the official water temperature. Where the average measured figure is above 27 °C, the highest measured temperature will be considered as the official water temperature.

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Hiller, W.D.B. (2020). Triathlon Race Day Medical Care. In: Migliorini, S. (eds) Triathlon Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-22357-1_22

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DOI: https://doi.org/10.1007/978-3-030-22357-1_22
Published: 07 November 2019
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