complication

Obstacle

A couple weeks ago I wrote about the medical toll at long-distance running events. There was also a recent report on the medical toll at an obstacle course race that caught my eye. On the face of it, the findings were surprising!

At the outset, let me issue a disclaimer. I haven’t participated–or even spectated–at one of these obstacle course races, so I may not have the best perspective. I’m talking, though, about races like the Tough Mudder, Warrior Dash, and Spartan Race, among others. They’ve become very, very popular very, very quickly. We’re talking 100’s of thousands of participants per year in the U.S. One day, I’ll give it a try. I’ll need to be brave!

The Study

A group of investigators headed by Marna Greenberg, DO, MPH, in the Department of Emergency Medicine at Lehigh Valley Hospital reported on a collection of patients who required hospital care stemming from their participation in an obstacle course race. The event was the Tough Mudder Philadelphia race, held over the weekend of June 1, 2013. As you may know, the Tough Mudder races are characterized by a 10- to 12-mile course with a series of 20-25 obstacles spread over the course. By report, approximately 22,000 individuals participated in this particular race.

The investigators were the emergency room physicians at the hospital that was designated to care for participants who required hospital care for medical conditions or injuries that developed during the race. In a report in the Annals of Emergency Medicine entitled “Unique Obstacle Race Injuries at an Extreme Sports Event: A Case Series”, they share their first-hand experience which they characterized as surprising.

The Results

The report provides fair detail about 5 patients with “significant” injuries or diagnoses and compiles a list with pertinent findings in 43 total athletes who received care at the hospital. The 5 athletes with “significant” problems included:

18 year old with myocarditis (inflammation of the heart muscle) caused by electrical shock during the event. Required admission for 2 days. Self-limited.
28 year old with depressed level of consciousness and diagnoses of accelerated hypertension (high blood pressure) and pericarditis (inflammation of the sac that holds the heart). Required admission for 2 days. Self-limited.
31 year old right-sided weakness who was found to have a stroke, seizure, and dehydration. Required admission to the intensive care unit (ICU). Was discharged to a rehab facility and at the time of writing, had persistent weakness due to the stroke.
41 year old who experienced syncope (blacked out) after being shocked at an obstacle. He fell, causing lacerations to the face. He was discharged from the emergency room against medical advice to be hospitalized.
25 year old woman with near syncope (nearly blacking out) because of electrical shock. Required hospitalization for evaluation and was treated for dehydration and rhabdomyolosis (breakdown of muscle).

The 38 others had diagnoses that included: heat injury, sunburn, ear barotrauma (pressure injury), shoulder dislocation, patella dislocation, heat exhaustion, vomiting, renal failure, various contusion injuries, rib fracture, dehydration, asthma, seizure, leg fracture, ankle sprain, and elbow sprain, among others.

The Takehome Messages

You never read about the medical toll at running races that are shorter than half marathon distance. That’s not to say that athletes don’t have injuries or other medical problems manifest during those races. It’s just that athletes are usually responsible for their own medical care or receive their care from the emergency medical system (EMS), rather than by race-supplied medical volunteers. So nobody is keeping track of the “toll.”

This report is great peak into the issues with the obstacle races. Kudos to the authors for sharing their experience. Obviously, 43 victims among 22,000 participants is a small fraction. We might reasonably expect, though, that additional athletes with minor injuries or medical conditions did not visit the hospital for care.

Some thoughts….

At an obstacle course race, the obstacles present a challenge and risk that is different from just running. These events are certainly not risk-free.
There are typical medical issues like minor injuries, dehydration, and heat injury. Some injuries and medical problems may be due very specifically to the obstacles themselves.
There will also be injuries that may not be expected–either by the athletes or by the nearby healthcare workers. At this particular event, the myocarditis, pericarditis, stroke/seizure, and syncope diagnoses were examples. Electrical shock was an unexpected causative factor.
Athletes should keep the potential risks in mind when they decide to participate and exercise great care while participating.

Like I said at the top, I’ll probably be a participant at some point. But I’ll need to be brave!

Have you wondered about the “medical toll” at endurance sports events? By that, I mean the sum of all the medical problems that occur to atletes during their participation (and perhaps shortly afterwards as well).

It’s an interesting issue, with many practical implications. If you’re organizing a swim meet, you’d be interested in the likelihood of drowning. If you’re participating in a bicycle race, you’d be interested in the frequency of crash-related traumatic injuries. If you’re the spouse of a long-distance runner, you’d be interested in the likelihood of heart-problems for the participants of a marathon. Should your event have a “medical tent” to handle anticipated injuries or medical problems? Where should the medical tent be located and how should it be staffed? How should your local EMS system or hospital prepare to handle athlete-patients? You get the idea.

Yet surprisingly little has been written in the medical and scientific literature about the medical toll of endurance events. There’s probably a bunch of reasons, including the fact that nobody in particular’s keeping track.

This past week there was an interesting report in the British Medical Journal from a group of investigators in Cape Town, South Africa, and headed by Martin Schwellnus. The report, “Medical complications and deaths in 21 and 56 km road race runners: a 4-year prospective study in 65,865 runners–SAFER study I,” describes the “medical toll” at recent editions of the Two Oceans Marathon races. The report and the findings caught my eye.

The Study

The participants in the study were the 65,865 runners who took part in either the 21 km half marathon or 56 km ultra marathon, the premier events at the Two Oceans Marathon races that are held each year in Cape Town, South Africa. They focused on the 2008 through 2011 editions. The weather conditions for these races was generally favorable, with temperatures ranging from 11.5 to 18.2 degress C and relative humidity ranging from 77% to 93%.

Like many long distance running events, these races had an elaborate set-up for provision of medical care on race day, including on-route medical stations, a dedicated medical facility at the finish, and designated hospitals where athlete-patients would be transferred should they need emergency care. Because the system for medical care was so well proscribed, the investigators were able to compile a list of all “medical complications” that occured in the race participants.

The investigators did not consider the most minor of medical complications, such as seeking medical attention at various first-aid stations for minor injuries or requiring physical therapy attention at the finish line. For simplicity, “medical complication” was defined as an episode that required the attention of a doctor. Exercise-associated muscle cramps alone were not considered a “medical complication” unless there were additional symptoms such as confusion, dizziness, nausea, or vomiting. A serious medical complication was defined as a “medical complication that could result in death unless urgently diagnoses and treated.” And finally, deaths were recorded as well.

The Results

Of the 65,865 participants, 64,420 (97.8%) finished their race(s). The finishing rate was 99% for the 21 km races and 97% for the 56 km races.

Two deaths were documented, each in a 21 km race. The fatality rate, then, was approximately 1 per 20,000 participants in the 21 km races. There were no deaths in the 56 km races.

Overall, there were 545 medical complications among the 65,865 participants, a rate of approximately 0.8% (8.27 per 1000 participants). The rate was approximately 0.5% for participants in the 21 km races and 1.3% for participants in the 56 km races.

Included in the 545 total medical complications were 37 that were designated as serious medical complications. This is a rate of approximately 0.06% (0.56 per 1000 participants). There was no significant difference in the overall rate of serious medical complications based on the distance of the race. The serious life-threatening medical complications included:

Ischemic heart disease (including successful resuscitation from cardiac arrest), in 3 runners
Myocarditis, in 2 runners
Serious cardiac arrhythmias, in 2 runners
Symptomatic hyponatremia (low sodium), in 9 runners
Serious metabolic complications, in 5 runners
Serious heat-related disorders in 7 runners (1 with hypothermia, 6 with hyperthermia)
Pulmonary edema, in 2 runners
Serious fluid, electrolyte, or acid-base abnormalities, in 4 runners
Bronchospasm, in 2 runners
Convulsions, in 1 runner

Further statistical analysis was used to evaluate groups of medical complications, depending upon the body’s organ system that was involved. In this analysis, the frequency of complications involving the cardiovascular, musculoskeletal, metabolic, gastrointestinal, and respiratory systems was greater among the 56 km runners than for the 21 km runners.

The Takehome Messages

The chances of a medical complication or serious medical complication were small, for both of the race distances. Athletes should know, then, that these risks are small as they consider participation in an event.

Information like this should inform safety planning on the part of event directors, event medical directors, and events’ local medical communities.

I suspect that the results are generalizable to races outside of South Africa and also to the real-world question of half marathon vs. marathon races which would be typical distances in the United States.

It is a somewhat surprising finding that the only 2 deaths occurred in the shorter, 21 km races. We know from recent detailed studies involving millions of runners that the risk of sudden cardiac arrest at long-distance running events is almost 3 times higher for marathon runners than for half marathon runners. In this study, it’s a statistical oddity–that not enough years were considered to evaluate such a rare end point.

Intuitively, it is not surprising that there would be more medical complications in the longer events. If nothing else, there is more “time exposure”–more athlete-hours spent in strenuous exercise.

I am surprised, though, that the frequency of serious, life-threatening, medical complications was similar for the 2 race distances, I would have guessed that these, too, would be more common in the longer distance races. Perhaps the take home message is the converse–that a shorter race is not necessarily safer when it comes to life-threatening medical complications. And the real world consequence would be that half marathoners not give short shrift to their health before participating.

Lastly, I’ll continue to hope that national governing bodies and large event organizers (eg, World Triathlon Corporation [WTC[) might collect and disseminate information about the “medical toll” at their races. As a sporting community, we would all benefit.

Writing on…

Medical Toll at Obstacle Race

The Medical Toll at Endurance Events