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Prepared by
Triathlon Canada
Medical Committee
July 2000
The following people have contributed to the development of this manual: (Chair, Triathlon Canada Medical Committee) TABLE OF CONTENTS:
The Triathlon is a competition composed of three distinct races: swimming, cycling and running.
Each leg of the competition carries the potential for both major and minor injury to theparticipant. Those responsible for the organization of a triathlon must ensure that appropriatepersonnel and equipment are available for the treatment of all injuries requiring medicalattention. Prudent medical directors should consider enlisting the first-aider support provided bywell-equipped and trained volunteer groups such as St. John’s Ambulance or Canadian SkiPatrol.
The swimming leg has the potential for major problems because of hypothermia, exhaustion,drowning and near drowning, as well as digital, facial and eye trauma from contact whenswimmers collide with one another. Open water swim courses present additional risks such aspanic attacks, toxic chemical and/or biological infectious agents, and, if held in salt water, thereis the possibility of man ‘o’ war and jellyfish stings. Equipment to record rectal temperature, re-warm the athlete, and transport him/her to a hospital (once stabilized) must be provided.
The cycling leg exposes the athlete to the risk of head and spinal injuries, abrasions andfractures. Personnel trained in the treatment of such injuries must be available as well asequipment for transportation, such as a spinal board and an ambulance. Protocols should bedeveloped in advance of the race for transport of serious injuries to the nearest hospital.
The run segment of a triathlon also exposes the athlete to injuries which are unique to thatparticular sport. Athletes at this stage of the race often ignore warnings of pain and/orexhaustion. Personnel and supplies must be available to commence the cooling-down process ofan overheated athlete. Competitors must be closely monitored, and transportation for immediateevacuation must be on hand, should that be deemed necessary.
Physicians who cover triathlon events require detailed knowledge on the management of suchrace site emergencies as hypo- and hyperthermia, cardio-respiratory emergencies and trauma.
The following Manual is intended as a guide for the health care practitioner who is approached toprovide medical care during a triathlon. These guidelines encompass the International TriathlonUnion (ITU) medical care guidelines. It is hoped that the Manual will serve to inform raceorganizers about the various problems that can occur, and the type of coverage we hope all willendeavour to provide. It is recommended that a race be fully covered encompassing theguidelines in this manual. It is the responsibility of the Race Director and the Race MedicalDirector (RMD) to decide whether the level of coverage provided for a particular race isadequate.
The Race Medical Director (RMD) shall be a physician designated by the Local OrganizingCommittee (LOC), who explicitly assumes responsibility for appointing the other medicalpersonnel for race day, organizing the medical tent, and equipping it with proper supplies. Thisperson must be experienced in medical care during multi-sport/endurance competitions. Ideally,the RMD should be a qualified emergentologist/intensivist or diploma graduate of the CanadianAssociation of Sports Medicine (CASM). If the RMD does not feel that the guidelines have beensatisfactorily met, then he/she has the option to decline to cover the race.
The RMD shall be responsible to the triathletes firstly, and the Race Director secondly. Anyallied health care workers involved in volunteering their services (i.e. nurses, chiropractors,athletic therapists, etc.), shall be responsible to the RMD and hence, the Race Director.
This manual was prepared with the Olympic distance in mind: a 1.5 km swim, a 40 km cycle anda 10 km run. It was not intended that this guide provide a detailed account on treatment of themedical problems encountered in a triathlon; rather it was written to highlight those medicalemergencies which may occur during the competition, to provide suggestions on how to preventthem, and to detail the supplies and personnel which are best utilized in treating problems thatmay arise.
A bibliography of recommended reading has been appended (Appendix 8) to provide the readerwith references on subjects of interest to the RMD.
Other appendices include a list of specific medical conditions to prepare for, recommendedpersonnel, recommended medical supplies, fluid station requirements, an injury reporting form,and an emergency medical plan checklist.
This paper is a guide for the following type of triathlon: The race begins with a 1.5 km swimalong a square or pennant-shaped course. The swim may also be a point-to-point race, whereswimmers exit 1.5 km from where they started. The swimmers then enter a transition zone,where they don helmets, cycling shoes and a race number. They may choose to stay in theirswimsuits, trisuits or change into cycling shorts. The triathletes then mount bicycles and head outonto the 40 km cycle route, usually an out-and-back or loop course. When the cyclists havereturn to the transition zone, they dismount, take off their helmet and cycling shoes, change intorunning shoes and start on the 10 km run. At this point, athletes may not run their best, as theirlegs are fatigued by the cycling.
It is essential that a physician serve as the RMD for a triathlon. The RMD's status as an MDbecomes an asset when obtaining actual emergency supplies (such as I.V. supplies), as well as inunderstanding when, how, and where specialized equipment may need to be used. It isrecommended that there also be a Medical Coordinator. This person does not have to be an MDbut must have medical experience and liaise closely with the RMD. Their job is to make sure allthe supplies and people make it to the appointed place on race day and to keep things runningsmoothly.
When planning the placement of people on the course, thought should be given to placingexperienced medical personnel with those who are less experienced. The level of training of allthe members of the medical team, including any specific skills, should be known well in advance(see Appendix 2 for Personnel). Physiotherapists for example, may not be inherently qualifiedfor the treatment of acute injuries, while Certified Athletic Therapists are. Physiotherapists withSports Physiotherapy Division (S.P.D) Level II and above are knowledgeable in handling on-siteemergency care and sports injuries. Similarly, nurses are generally more appropriately trained forthe type of care that is required at the finish line, e.g., the monitoring of patients withhyperthermia and/or the administration of I.V.s, rather than acute injury management.
Chiropractors are neither trained nor licensed to manage cardio-respiratory or other medicalemergencies, and should therefore not be substituted for the medical personnel mentioned above.
Canadian Ski Patrol members usually carry their own supplies to treat injuries, and are wellversed at the level of a first responder in triaging, stabilizing and managing injuries out on thecourse. They are also very helpful in the finish line area, as are Sports First Aiders. Massagetherapy is something that is often useful at races (i.e. the athletes like it), but it has no place inthe acute care Medical Tent. Provision must be made to transport an athlete to the Medical Tentif necessary.
It is important, when requesting the services of a physician to cover an event, that at least threemonths', and preferably six months' advance notice is given in order to acquire commitmentsfrom other medical personnel and to organize all of the necessary equipment.
From an officiating point of view, an out-and-back course for all legs of the race is preferable.
Medical coverage is more efficient when only one main medical tent is required. Other coursedesigns however, can be allowed if adequate equipment and personnel can be obtained to coverthe number of first aid stations required. Another option is to move all the equipment from onearea back to the main medical tent once that portion of the race is finished, but this becomeslogistically more difficult.
The entire medical team must be properly identified so that in an emergency situation a teammember is highly visible. For example, physicians may be specifically identified by the initials"M.D." on the visor of a cap or on a T-shirt. This identification is important to ensure that notime is wasted deciding who is handling the emergency. The public also needs to know that theemergency is being handled by appropriately trained personnel.
The Medical Tent must be clearly identified by appropriate signs. All race volunteers, officials,marshals, police officers, etc. should be aware of its location.
A medical form (Appendix 6) should be printed on the back of the race numbers, and be filled inbefore the race. It should be done with indelible ink, and include the athlete's name, informationon present and past major medical conditions, medications, allergies, name of physician, and thename and number of a person to contact in an emergency. If the form was not printed on the backof the number, the information can still be written on the number at the time of registration. Asthis system is not foolproof, it is helpful to have a list in the Medical Tent of race participantsand all the above information. This is easy to do by computer if the information is keyed in at thesame time as the name, address, age and race number.
The organization of the race depends on the coordination of duties between the medical team andrace officials. A decision must be made by RMD as to what emergencies the medical team willbe prepared for. Advanced Cardiac Life Support by provincially trained paramedics is of greatbenefit if available. For cardiac arrythmias, a defibrillator is crucial in properly trained hands.
Unless a crash cart containing the required ACLS drugs is available, a defibrillator is effectiveonly for converting potentially fatal rhythms like ventricular fibrillation. It is not appropriate tohave a physician arrive to provide coverage at a race with no more than a First Aid kit.
Alternatively, if the RMD has been promised a certain amount of equipment by the race director,and shows up at the race to find that these items have been cut due to budget restraints, this willseriously compromise his/her ability to provide optimal medical care.
A list of supplies necessary to cover a race has been drawn up with a separate section thatincludes equipment required to handle cardiac emergencies. Specific quantities have not beenincluded as this will depend on predicted race conditions, the number of participants, and thelocation and number of medical stations (see Appendix 3).
ITU rules require that there be a minimum of 2 ambulances, or 4 per 1000 athletes. Ideally, one ambulance should be at the finish line and one on the course. Smaller races can often get by withan ambulance on site that may get called away during the event and/or a fully equipped van onthe course at all times. The ambulance(s) should have direct DEDICATED communication(radio and/or cellular phones) with the Medical Tent. The ambulance(s) should also be equippedwith cardio-pulmonary resuscitation supplies and trained personnel. The ambulance(s) must haveeasy and unobstructed access to the finish line and the medical tent.
Many race directors feel that St. John Ambulance is adequate for this service - they are not.
St. John Ambulance personnel are generally NOT permitted to transport patients; rather, theycome in and set up their Mobile First Aid Posts on site. The attendants do have First Aid andcardio-pulmonary resuscitation (CPR) training, and can therefore deal with some injuries andminor emergencies. They thus function in much the same way as the Canadian Ski Patrol – asfirst responders. More serious and/or life-threatening accidents and injuries require adjunctiveequipment and back-up assistance from physicians and the regular ambulance service. (N.B.
Regulations may vary from province to province, so it is advisable to check with each localorganization regarding their qualifications and authority.) MEDICAL SUPPORT VANS:
It is also very useful to have mobile medical vans that patrol the cycling and run routes. Theseshould be staffed by a physician, a second member of the medical team and one person toestablish and maintain communications. The van must be equipped with emergency and first aidsupplies. One of the vans should be a sweep vehicle and follow the last athlete to the finish line.
There should be a plan made in advance to transport injured athletes who are non-emergencycases from the course back to the Medical Tent. The number of vans will depend on the racecourse and the number of ambulances available. One van per 350 participants would be areasonable ratio.
A good communications system is essential. A telephone or cellular phone must be in or verynear the Medical Tent. If possible there should be communications people with radios situatedalong the course using a medical-only frequency that is linked to the ambulances, the Zodiacs(boats on the swim course), mobile vans, the Medical Tent and First Aid stations along thecourse. A system that only uses the race officials' communication system is not as failure-proof.
Before the race, the hospitals in the area should be advised about the race, numbers ofcompetitors and the type of injuries that might be expected. On the day of the race it is a goodidea for the RMD to talk directly to the emergency room (ER) physician on duty. The ER doctorshould also be contacted directly when an athlete is being sent to the hospital. For this purpose, alist of all important medical phone numbers should be prepared in advance, and given to allmedical personnel.
Follow-up should be done on each athlete admitted to hospital. If an athlete is injured on course and transported to hospital, or is in the Medical Tent being treated for a serious problem, theRMD should inform the race organizer and announcer. They can then attempt to locate theathlete's family or friends and keep them informed. Due respect for patient confidentiality andconsent should of course be adhered to.
Medical records should be kept on each athlete treated. This is often difficult in a busy MedicalTent, however it is very important to gather statistics for planning the next event and forprotection in the event of a medico-legal case. If possible, duplicate or triplicate forms should beused, so that copies can be sent with an athlete to the hospital. There are some excellent formsavailable through the Sports Medicine Council of B.C. for a nominal fee (Appendix 6). Theseinclude a waiver section that the athlete and medical team member sign should the athlete decideto leave the medical area and/or return to the race against medical advice. Other races have optedfor a card that can be tied on a string around the athlete's neck, which has to be turned in beforethe athlete can leave the Medical Tent.
If the event is a sanctioned event, drug testing may be required. This is generally organized bythe sport governing body, but it often falls to the RMD to incorporate the testing into the medicalcoverage of the race. This involves such things as the location of the testing, the physical set-upand the fluids that the athletes can consume. It is best to check these regulations (available fromthe Canadian Centre for Ethics in Sport web page at well before the event. If thedrug testing area is located some distance from the main Medical Tent, then consideration shouldbe given to having a physician and/or nurse, and some medical supplies such as I.V. fluidsavailable for any athlete that might require such assistance.
Medical protocols should be written up well before the race, distributed to all the race workersand reviewed at one of the general meetings close to the time of the race. The Race MedicalDirector should conduct an orientation session with the medical team reviewing protocols, goingover probable race day scenarios, including treatment of hypo- and hyperthermia, and athleteevacuation from all areas of the racecourse.
Participant education is an important part of the RMD's job. Newspaper articles, seminars, etc.
can be used to educate triathletes about the medical problems that can be encountered in a raceand how to prevent them. Pre-race announcements give the RMD an opportunity to warn theathletes of any day-of-race hazards, such as temperature extremes and adverse weather conditions. A physician may elect to fly a coloured flag from the Medical Tent indicating theenvironmental risk. The use of a wet bulb thermometer on race day can accurately predict thepossibility of extremes of temperature, wind and humidity and hence the probability of injurydue to the environment.
Traffic control on the course and around the transition areas, finish chute, and medical tentshould be given priority. A method should be devised to keep unauthorized people (especiallythe media) out of the medical tent. Family members or friends may accompany an injuredathlete, if necessary, but the numbers need to be limited. The medical tent cannot function at itsoptimal efficiency if these security measures are not taken. A volunteer and/or police officershould coordinate traffic control. Remember that every attempt should be made to preserve theathletes’ confidentiality and dignity while being treated.
Liability insurance must be purchased separately for each event, generally through the provincialsport governing body. Specific provisions for medical and paramedical volunteers must beincluded in the policies. Many of the medical personal will already have their own coverage e.g.
physicians should be covered under the Canadian Medical Protective Association, but it isalways wise to double-check this important issue.
Race waivers on the entry form must be signed by all participants. The wording should beconcise and specific. Note that ITU and Triathlon Canada rules give officials and medical teammembers the right to pull an athlete from the race for any health or safety-related reason. It isimportant that any medical team member that pulls an athlete from a race be fully supported inthis decision by the RMD and other members of the medical staff.
Evaluation and treatment of a triathlete may not mean disqualification, unless it involvestransport of the athlete, administration of I.V. fluids, or similar medical treatment.
There should be a budget for medical supplies. This is seldom included in the budgetary planningfor the race. Many medical supplies can be borrowed and returned at the end of the race, but notall supplies can be procured this way. Every effort should be made to fund replacement of anyused supplies from the physicians' medical bags, or therapists' first aid kits.
The medical team all volunteer their time and expertise, and do not get reimbursed fromprovincial medical plans for any medical treatments provided. Therefore, race officials shouldprovide anything that they can in the way of T-shirts, caps, lunches, parking passes, etc. as"perks" for the many hours of donated volunteer time.
Swim Leg:
The swim section of the triathlon course is potentially the most dangerous. If an athleteexperiences cramps, fatigue or cold, the result could be death. Any athlete can suffer cramps, butinexperienced athletes may over-extend themselves and/or eat too much before the race. Fatigueis often the result of poor stroke technique combined with a low level of fitness for swimming.
Many athletes attempt triathlons even though they are not very good swimmers, and fatiguecombined with cold water can be a fatal combination. In Olympic distance triathlons, a goodswimmer will be in the water for less than 25 minutes, a poor swimmer as long as 45 minutes.
Combine the latter with the low percentage of body fat usually present in the average triathlete,and the result can be hypothermia and potential death.
Hypothermia should be suspected in any competitor pulled from the water; a rectal temperaturemust be taken to document the exact temperature. Special low reading rectal thermometers(down to 30 degrees C) must be used. Most athletes can be warmed by the use of blankets and awarm drink, but removal of a wet bathing suit and warm bottles placed under the axilla and onthe groin area will help raise body temperatures in more serious cases. A few will need to havean I.V. inserted, using a warmed solution. I.V. bags can be easily heated in a microwave ovenbetween one to three minutes on high (take off the outer plastic covering first!). Hypovolemia isa component of most thermoregulatory problems, so fluid replacement should be carried out witheither oral or I.V. fluids.
All of the above measures should be available for use at the swim area. It is helpful to havepropane heaters and/or space blankets in the tent. In some race locations where cold watertemperatures are the norm, heaters become an essential item. Triathlons are often held in isolatedlocations, and sending a hypothermic patient for a long ambulance ride without first undertakingre-warming measures, can potentially be life threatening.
Another common danger is the potential contact between competitors. An accidental kick in theface may cause an athlete to submerge. With numerous competitors racing to overcome oneanother there is a significant possibility of failing to spot a swimmer in trouble. In some eventswhere the risk is extremely high, underwater S.C.U.B.A. divers may be used. There should alsobe a mechanism to verify that all competitors have emerged from the water and have passedthrough the transition area.
Dangerous situations in the swim leg may be reduced by the following measures: Ensure the start area is safe i.e. the water entry point must be free of obstructions such asposts and boulders. The transition area should be free of rocks and provide good non-slippery footing.
Have a low ratio of swimmers to safety guards (lifeguards and people in boats).
Choose a safe start method (see below).
Limit the number of people allowed in a mass start.
Use a square or pennant-shaped course.
Have clear guidelines of when a race will be cancelled or the course shortened and have this decision lie with the Lifeguard Co-ordinator, the Medical Director, and theTechnical Delegate to the race.
Safety for the swimming leg should be organized by the Lifeguard Co-ordinator. The safetyguard (lifeguards and people in boats) should utilize different modes of transportation withvarying levels of training. Qualified lifeguards on rescue boards should be spaced evenly alongthe course line to rescue swimmers at risk of drowning. The Royal Life Saving Societyrecommends one guard for every 25 swimmers. Volunteers in motorboats should be available totransport swimmers rescued by the lifeguards. Zodiac boats work well for this; 5 boats per 1000participants is recommended. Once back at shore there must be a fast and easy way to transportthe athlete to medical care. Volunteers in kayaks and canoes, with lines from the sterns of theirboats, can be used to help tired swimmers back to shore. Most importantly, there must becooperation and communication with the personnel in the Medical Tent, in order to ensurecontinuity of care of an injured athlete.
Triathlon start methods are as varied as the race course itself. Here are a few of the mostcommonly used starts: Competitors begin on shore and, at the sound of the gun, run into the water.
Some athletes start in the water and some on shore.
Athletes gather on shore or on a dock. A few minutes before the gun sounds competitorsenter the water and gather behind a starting line, standing about waist deep in the water.
As in number 3, but the athletes have to tread water. There is some jockeying for positionby contenders but in general, competitors seed themselves. Poor swimmers tend not toenter the water early as they do not want to tread water for an extended length of time.
This may be reinforced with an announcement before starting time. Slower swimmerstrail the pack, which will reduce potential contact with other competitors. When a racestarts with the competitors treading water there is less chance of swimmers going overthose in front (a real problem when the race starts with a run into the water).
The maximum number of athletes that should participate in a mass start is 400. If more athletesmust be accommodated a wave start should be used. Waves may be determined by swim time orby age groups. All athletes must have numbers drawn on their bodies with waterproof pens and have numbered caps. This helps with officiating, and provides essential information if there is amishap.
Bright caps greatly improve the visibility of swimmers; neon coloured caps are best. Markerslining the course should be a different colour from the caps. Some races use different colouredcaps for the different waves of swimmers. Consideration could be given to identifying athleteswith pre-existing medical problems with a different style or colour of cap. In this way, they couldbe tracked through the swim part of the triathlon, and picked up by number when they enter thetransition area.
The design of the course adds to its safety. A square or pennant-shaped course paralleling theshoreline is the safest. The finish area of the swim must also be designed for maximum safety ofthe swimmers. The formation of a narrow funnel at the finish allows all competitors to beassessed by race marshals for signs of fatigue and/or hypothermia. The ground area both in thewater and on shore should be as solid as possible in order to provide for a firm foothold, andshould be a material that can be run on in bare feet. Laid down surfaces such as astro-turf, oftenlift as competitors run over it. It is essential to have volunteers stationed at hazardous areas towarn the athletes.
A policy must be formulated prior to race day to stipulate issues such as when to cancel a race.
Many environmental conditions contribute to the relative safety of the race but main factorsinclude water temperature, current, lightning, visibility and fecal coliform count. Despitetentative research done in the area, a definitive answer on when to cancel a race due to watertemperature still cannot be given. It would appear that body composition is very important in aperson's thermal response to swimming in cold water, since subcutaneous fat is the primaryinsulator against body heat loss in water.
For a group of athletes with a wide range of body composition and swimming ability, the lowerlimit would be 13 degrees C and the competitors would have to wear wetsuits or vests. TriathlonCanada and ITU have water temperature charts, which indicate temperatures at which the athletemay or may not wear wetsuits. If the water temperature drops below 13 degrees C or if lightningis present, the swim portion of the race should be cancelled (or the entire race, depending onseverity and duration). To guard against individual variation in reaction to water temperature,competitors must be allowed to wear wetsuits and/or insulated caps if they feel the need whenthe water temperature is under 22 degrees. The current Triathlon Canada guidelines for wearingwetsuits for age-groupers and juniors, are as follows; wetsuits are not allowed at watertemperatures above 22 degrees C. Wet suits are mandatory for distances 2000 m or less & below14 degrees C, for 2000-3000 m & below 15 degrees C, 3000-4000 m & below 16 degrees C.
Visibility is also important. If the wave chop is so great that a swimmer can not be seen by thefirst level of guards (i.e. those lying on paddle boards), then the swim course should be shortenedor altered, or as a last resort, cancelled. Also, if swimmers cannot see course markers easily, theswim should be cancelled as they will expend too much energy stopping in order to redirectthemselves.
Water quality is an area of safety often overlooked. Appendix 8 lists a website for Health Canada, which has an article on Recreational Water Safety Guidelines, which will help to ensurethe water quality of the swim is appropriate.
Cycle Leg:
The cycle leg of a triathlon also has the potential to result in hypothermia. However, injuriesfrom collisions, and problems associated with exhaustion and hyperthermia are more common.
Collisions do not occur frequently in age group triathlons, because of the "no drafting" rule: agegroup athletes are required to stay a specified distance away from each other on the cycle course.
(Note that elite athletes may race in a separate, draft legal wave). The following measures help toreduce collisions: 1) The "no drafting" rule in age group races is an important aspect of safety, as well as being essential for a fair race. Officials should be assigned to monitor the course and have thepower to penalize competitors who are breaking the rules.
2) Choose the safest possible bike route when designing the course. The route should be away from major roads, yet be over a quality surface. All major intersections should bemanned by police personnel and/or professional flag people and volunteers, and all otherintersections and hazards should be staffed by volunteer race marshals. Any manhole orroad indentation should be clearly marked before the event, or be blocked off. The roadinto and out of the transition area must be closed to cars. All major corners should have atleast one marshal and a hand broom to sweep the road clear of gravel; the entire bikecourse should be swept by machine the day before or the morning of the race. Railroadcrossings must be well marked, with the tracks covered if possible, and a marshal shouldbe present to warn competitors of the hazard. It is also important to check train schedulesahead of time to ensure the race will not be interrupted by train traffic.
3) Bikes should pass a bike inspection prior to the race in order to decrease the chance of mechanical failure. The bike inspection should include, but not be limited to: helmet(damage, chin straps properly in place), both brakes functioning properly, tires in goodshape, headset and seat-post secure.
Problems with heat regulation may be prevented by wearing appropriate clothing and by payingclose attention to hydration. Competitors should be advised to carry their own liquids, whichshould include at least two bottles on a hot day. Race organizers should also provide at least one(and preferably two) water stations. See Appendix 4 for Fluid Stations.
All competitors must wear cycle helmets at all times during the bike portion of the race, toprevent head injuries. This is clearly stated in both the Triathlon Canada and ITU Rules. Helmetsmust meet the American National Standards Institute (ANSI) and/or the Snell Foundationrecommendations. Helmets should be inspected in the pre-race bike check. During the race, anofficial should check that helmets are on and done up before the athlete takes their bike out of thebike rack. Those without a helmet will be sent back to get one, and will not be allowed toproceed until they have one. The helmet must remain done up until the athlete has re-racked theirbike back in the transition zone.
If a collision does occur, proper communication via radio transmission is essential to transportmedical personnel to the injured athlete. It is often possible to arrange coverage by a local radioclub and it is helpful to have one operator at each first aid station, particularly at those bases thatare manned by a physician.
Adequate preparations must be made for the transport of an injured competitor from the bikecourse. A system for requesting ambulance assistance should be outlined to all members of themedical team, race officials, volunteers and radio personnel. Arrangements must be made aheadof time for the management of serious neck and spinal injuries, as well as fractures.
The location of First Aid stations and the manning of these stations is very important. First aidstations should be situated near high-risk areas (e.g., at the bottom of major hills) and should bemarked on the official course map. Athletic therapists, sports physiotherapists, sport First Aidersand nurses should work alongside physicians, and special designation should be given to thosestations which have physicians.
Running Leg:
This leg comes with its own set of problems, which are normally seen at any 10 km race. Theseproblems are compounded by exhaustion, as it is the last leg of the event. Hypothermia andhyperthermia are common, and obviously are related to the conditions on race day, however it isimportant to remember that both can occur on the same day.
The salient points of prevention of thermal injuries like hypo/hyperthermia include: § racers and officials must understand the risk of thermal injury and how to minimize it§ race officials should consult local weather authorities in order to plan races for the coolest § on the day of the race weather conditions must be assessed and appropriate action taken§ participants must be educated on the risks and how to prevent thermal injury§ enough emphasis cannot be place on the importance of adequate fluid stations for the Consideration should be given to making the running route a lap course. This allows the officialsto view more of the race and therefore observe runners in difficulty.
Appendix 1
Specific Medical Conditions to Prepare for:

Ø Exercise induced reactive airways or bronchospasm Ø Sundry blisters, abrasions and friction burns Ø Major and minor musculoskeletal trauma Appendix 2

Ø 1 Race Medical Director (physician)Ø 1 physician for every 200 athletesØ Paramedics, Emergency Medical Technicians or ambulance attendantsØ 1 paramedical person in the Medical Tent for every 100 athletes (nurses, physiotherapists, Ø 1 on-course Sports First Aid person for every 50 participants (e.g. Canadian Ski Patrol, St. John Ambulance, Sport First Aiders, athletic therapists, physiotherapists).
N.B. Registered Massage Therapists should not take the place of medical personnel. Ifavailable they can work under the supervision of the RMD as and work in an areaseparate but adjacent to the acute care Medical Tent. It is often helpful to have a MedicalCo-ordinator to help organize and procure medical supplies, oversee communicationsetc. The Co-ordinator does not need to be a physician.
Ø Lifeguard Co-ordinator to arrange and oversee the swim leg and to report directly to the Ø 1 lifeguard for every 25 athletes in an open-water swim.
Note: the RMD has the authority to change the requirements for personnel, including the numberof ambulances, depending on anticipated weather conditions, number of participants, type ofcourse, access to hospitals etc., unless it is a ITU sanctioned race, where the original guidelinesshould hold.
Appendix 3
Medical Supplies and Triage

Main Medical Tent
q Located adjacent to the finish lineq Medical tent for each transition area (if more than one)q The tent must be big enough to contain cots for 5% of the competitors, a communication q Portable cots/beds, sufficient for 5% of the total number of competitors.
q Ice: 1 kg per 4 competitors, include sufficient plastic bagsq Oral fluids: 1 litre of water per 5 competitors; sufficient cupsq Blankets and towels for 15% of competitorsq Telephone or cell phone in the tent or close byq Radio at the tent for communication with on-course medical personnel and ambulance(s)q Warm fluids and hot water bottles for treatment of hypothermia. It is also useful to have a method to warm the I.V. solution and the water bottles. Propane heaters are necessary forswims held in cold water.
q Important to have receptacles for vomit; a common problem in the medical tent.
q Important to have lots of garbage bags, paper towels, cleaning fluid, etc.
q Have pen and paper available to record patient information and to keep an injury logq A system must be set up for triaging and a separate area set aside for more serious cases.
q Drop sheets to separate beds, to maintain patient confidentiality and athlete dignity.
q Medical team members should be in the finishing chute and circulating through the post- race areas, to identify anyone having problems.
q Communication from the first aid stations along the course should identify athletes (by sex, description and race number) who look as if they could be a potential medicalproblem.
q Large signs to identify medical areas are essential. These should be made up ahead of Essential Emergency Supplies
The following is an example only, and should not be interpreted as a complete list.
q Ambu Bag and Laedrle maskq Oxygen tank, delivery tubing, fittingsq Airways of various sizesq Laryngoscope and endotracheal tubesq Portable suction is very helpful (a turkey baster will do)q I.V. Set-ups for 10% of competitors with 1 litre of fluid per set-upq I.V. poles (can be improvised using clothes line, hangers, etc.)q Parentral I.V. solution for volume expansion, glycemic correction and hypovolemiaq Alcohol swabs,q I.V. cannulas,q I.V. administration sets,q I.V. arm boardsq Opsite, tourniquetq Micropore tape q Scissorsq Cling wrapq Latex glovesq BP cuff (normal and large sized)q Stethoscopeq Reflex hammerq Penlightq Oto/ophthalmoscopeq Rectal thermometers, both standard and hypothermic (reads down to 30 degrees C) Tympanic thermometers are not recommended as they can result in false readings.
q Sundry wound and burn dressingsq Nasal packingq Eye wash and patches Medications:
q Ventolin inhaler
q 50 ml Dextrose injectable or Instaglucose
q Nitroglycerin spray or sublingual Nitroglycerin
q Adrenaline 1:1000 and/or Ana-Kit
q Diazepam/Midazolam in appropriate doses
q Injectable narcotics if available
q Injectable Naloxone
q Syringes, needles and needle disposal kit
q Xylocaine: local/parentral and gel forms
Serious thought should be given to having equipment on hand to handle a cardiac arrest; not allcompetitors are young and healthy. These supplies are required if the race is to be ITUsanctioned: q ECG/Defibrillators; 2 available and testedq ECG leads, contact gelq Ambubag, oxygenq airways of various sizes, laryngoscope and endotracheal tubesq drugs currently recommended by A.C.L.S. guidelinesq portable suctionq McGill forceps General Supplies

q Ativan S.L.
q Gravol 50 mg p.o. and 50 mg/ml IMq Tylenol/ ASAq Gelusilq Non-steroidal anti-inflammatories Wound and Fracture Care: to care for up to 5% of competitors
q Betadineq Xylocaine: local/parentral and gelq Surgical scrub brushes (betadine)q Polysporinq Gauzeq Cling wrapq Spray Bactinq Steristripsq Elastoplast in different sizesq Splintsq Triangle bandagesq Moleskinq Glovesq Suture material and needles Supplies Specific for Swim Area:
q Rectal thermometers that read down to 30 degrees Cq Warm fluids for oral useq Hot water bottles and a method for heating bottles and I.V. solutionq Wool blankets and/or space blanketsq Towelsq Propane heaters Supplies Specific for Cycle Area:
q Hypothermic rectal thermometersq Wound and fracture care suppliesq Xylocaine sprayq Surgical scrub brushesq Access to a spinal board Supplies Specific for Run Area:
q Rectal thermometersq Ice and plastic bagsq Cool water and cupsq I.V. equipmentq Supplies for minor wound care Appendix 4
Fluid Stations

Swim Start:
q 200 ml of water per personq 100 ml of replacement fluid per person Swim Finish: (located at transition entrance)
q At 12 - 13 km pointq At 28 - 30 km pointq 350 ml water bottle per person Transition: (located at run departure gate)
q 2 cups per personq 200 ml of water per personq 1\2 orange per personq 100 ml replacement fluid/personq Ice 500 kg Run: (every 2 km)
q 3 cups per personq 200 ml of water per person, per stationq 100 ml of replacement fluid per person, per stationq Ice, 500 kg Finish Line Chute:
q 2 cups per personq 500 ml water per person Post Race Area (away from the finish chutes)
q 2 cups per personq 500 ml of water per personq Additional sealed fluids to include fruit juices and replacement drinksq Ice 500 kgq Food, including fruit, bagels, etc.
The above guidelines are from the ITU Operations Manual. The ice amounts are not given perperson and may be excessive for a small race. Approximately one kg of ice per four participants(total) should be disbursed between the medical tent, the ambulance and the medical vans.
Appendix 6
Sample Injury Reporting Form

Appendix 7
Emergency Medical Plans

Appendix 8

1. Canadian Academy of Sports Medicine (CASM)
This website outlines position papers on:§ HIV in Sports§ Female Athlete Triad§ Pregnancy§ Mandatory Use of Bicycle Helmets 2. Canadian Centre for Ethics in Sport (CCES)
This website has information on:§ Canadian Policy on Doping in Sport§ Medical Declaration form and medical waiver for athletes taking banned or restricted § Drug Classification booklet for Banned and Restricted Medications in Sport 3. Sport Medicine Council of British Columbia
4. Health Canada;ehp/ehd/catalogue/bch_pubs/recreational_water.htm
Guidelines for Canadian Recreational Water Quality 5. Triathlon Canada
Under National Federation, you will find the Competition Rules (ITU rules adapted foruse at local to National level events).
6. International Triathlon Union (ITU)
Under Rules, you will find the Operations Manual (outlines Medical Requirements forWorld Cup and World Championship races) and Rules (ITU Competition Rules).
The Medical Committees of Triathlon Canada and Triathlon BC cannot be held
responsible for any injury or loss of life which may arise as a result of the use or non-use of
this Triathlon Medical Manual.

The authors would be pleased to answer any questions concerning the contents of this manual.
For further information, you may contact Liz Graham at: 604-731-1924 This document has been edited and approved by The British Columbia Triathlon AssociationMedical Committee, July 1992.
This document was reviewed and revised by Dr. Alain Leblanc and Liz Graham, Chair, TriathlonCanada Medical Committee, in March 2000.
Use of any or all of this manual is not permitted without prior permission from Triathlon Canadaand/or Triathlon BC.


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