The document provides details on the medical operations and staffing for a large Ironman triathlon event. It discusses: 1. The medical tent serves a large role in the event and takes 5 months to organize, staffing over 100 medical professionals across various medical stations along the swim, bike, run courses and finish line. 2. The medical team prepares for common injuries and medical issues among athletes including heat illness, hyponatremia, cardiac problems, and provides protocols for rapid response and treatment. 3. On average, over 400 athletes finish the full ironman event each day, with most completing the run portion in the evening hours from 6-10pm. The medical operations aim to safely

1. Mass Sporting Event :
Sports Medicine
David Carfagno
D.O., C.A.Q.
Scottsdale Sports Medicine Institute

2. 1.
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3.
4.
PREPARATION OF THE EVENT
Swim
Bike
Run

3. 1.
2.
3.
4.
Course set up
Resources
Staff
Yourself

4. 
Swim
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Transition
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South Side Main Medical
North Side Warming
Men’s and Women’s Change Tent
Main Medical
Finish
 72 bed MASH unit
 Teams comprised of 3-4 staff per 6 bed section
 Evaluation/oral suport/IV support/Meds/Istat
 2 ALS ambulances and PM staff


5. 
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The Medical tent serves a
large role in the Ironman
and thus organization of
the medical team is
important and takes
shape nearly 5 months
before each race every
year.
The Medical team is
comprised of doctors,
nurses, paramedics,
EMT’s, medical students,
athletic trainers, and
other personnel such as
IV technicians and
communications,
security, and supply
volunteers.

6. 

Catchers are placed at the finish line. They
are educated on cooling down the athlete and
escorting those that need medical care.
At the beginning of the tent, we have a
computer check-in. Personnel will take the
athlete’s chip and the athlete is checked in.

7. 
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Swim Medical 5:30-9:00 am
South Main Tent (Swim Exit)
Hasan Chaudry MD/Gina Ferguson RN
Joe Garcia MD/Susan Girard RN
Alex Espinoza MD/Kelley Deeny RN/Terra Marr RN
Lainie Yarris MD/Sue White RN/Brad Williams PM
Jeff Jaco PA/Michelle Nelson RN/Mary Ellen Quinn NPEMT
Finish/Catching
Rodney Schnuelle EMT/Katie Sidesinger RN/Milica Mcdowell DPT/Conrad Hilton/Scott Simpson
North Medical Tent
Michelle Miller RN/Billy Burnett EMT/Brian Byars EMT
Main Medical Setup 8:00-10:00 am
Nicole Barreda ND/Maria Santander MD
Al Valle CPU/Craig Wolchover CPU/Alex Zdvorak CPU
Transition Medical 8:00-10:00 am
Brian Crowder RN/Jocelyn Mayes RN
Robyn Crowder/Paul Herberger
Transition Medical 12:00-5:30 pm
Men’s Tent: Savas Petrides MD (Sarah Petrides)/Bob Nelson MD
Ignacio Marquez EMT/Kenneth Zurcher/Michael Bishop PM
Women’s Test: Bridget Haga RN/Katie Hoodjer RN
Jim West PM/Sarah West RN/Lisa Sherry-Kulow RN/Sana
Shuttari NP/Angela Tetschner RN/Lori Vega RN

8. 
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Main Medical 12:00-3:00 pm
CPU: Jordan Ahern/Kali Bayes
A: Liz Dinsmoor RN/Mark Ford EMT
B: Ann Kelly RN/Judy Lynn PM/Deborah Ackerman RN
C: Tanya Marvin PA/Clare Ryan RN NP
Main Medical 3:00-6:00 pm
CPU: Jordan Ahern/Mikayla Jaraczewski/Jennifer Light
A: Liz Dinsmoor RN/Carly Fellhoelter CAN
B: Lyle Edwards PM/Praise Gunadi RN
C: Terra Marr RN/Jennifer Quint RN
D: Robert Ziltzer MD/Amy Turano RN/Rachel Dickman EMT
Run Medical 3:00-6:00 pm
Steven Cho/Jason Lee
Dina Utter RN/Praise Gunadi RN

9. 
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Main Medical 6:00-9:00 pm
CPU: Jordan Ahern/Darrin Anderson/Joseph Baxter/Samantha Calvin/Bonnie and Danny Kissinger/Sue Pierson/Annette Paris
A: Ryan Coates DO/Dan Leon PM/Roger Chopelas RN/Andrew Bliss EMT
B Dennis Scribner MD/Lisa Banyasz RN/Richard Alamo PM
C: Benjamin Johansen DO/Cliff Bailey RN/Rodney Schnuelle EMT
E: Amish Shah MD/Tara Peters RN/Dane Morrissey PM/Mark Thornberry PM
F: Mikyong Hand MD/Kimberli Haas RN//Tommy Roads/Kimberly Hansen ATC
G: Donn Hogan MD/Rachael Roberts RN/Desiree Hart-Wilson RN/Pamela Pimentel RN
H: Andrew Utter MD/ /Anna Lipa RN/Loren Swensen EMT
I: Lyle Edwards PM/Neil Martin PM/Kathy Brown RN/David Jordan PM
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Walking Wounded: Jay Mellen MD/Brian Moore MD/Carol Holliday RN/ Terra Marr RN/Charles Brown PM/Jennifer Sheneman RN
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Donovan Adendorf DC/Megan Cook/Jackie English/Carly Fellhoelter Crna/Cyntia Hurtado/Mikayla Jaraczewski/Bret Jones/Neal Mckimpson/Leonor
Medina/Anna Pastorino/Scott Simpson/Conrad Hilton/Josh Hendrix
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Catcher Assist: Ted McCarthy MD/Mike Pierson MD/Marita Mcgoldrick NP/Eric Loiland PT/Sarah Kellerhals/Yoonha Kim/ Matthew Petterson/Sarah
Rubenstein/Amber Sandoval-Menendez
Run Medical 6:00-9:00 pm
Patrick Weldon MD/Gary Young RN/Jude Carza RN/Raiza Carza RN
Charting: Gregg Bassett/Sam Fleischer
Assist: Joanne Donnelly Crna/James Fernandes PTATC/Jose Fonseca PT
Main Medical 9:00-12:30 am
CPU: Jordan Ahern/Cassie Beard/Tamara Brown/Michelle Drietz
A: Mike Brown DO/Lisa Austin RN/Brad Eppelheimer ATC
B: Matthew Duke DO/Zelda Carson RN/Brianna Foote RN
C: Savas Petrides MD (Sarah Petrides)/Carly Fellhoelter crna/Nathan Hill EMT
D: Richard Ernst MD/Yiselle Gonzalez RN/Chris Murray PM
E: Dana Jamison MD/Melissa Kay ATC
F: Amish Shah MD/Terra Marr RN
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Walking Wounded: Dennis Scribner MD/ Maya Davidow MD/Peggy Thornhill RN
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Tracy Lee/Chung-Kai Liu/
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Catcher Assist: Ted McCarthy MD/ Kelsey Picha ATC/Sharon Plummer ND
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Run Medical 9:00-12:30 am
Amy Wiser MD/Vicky Tippett MD/Kortney Parman RN
Evan Wolff/Russell McWilliam/Tina Rossi/Gillian Hansen

10. Ironman Average Finish Time
450
400
350
300
250
# of Athletes
Run:
200
150
100
50
0
Until 5pm
5pm-6pm
6pm-7pm
7pm-8pm
8pm-9pm
Time of Day
9pm-10pm
10pm-11pm
11pm+

11. 
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1. Drowning / Near-drowning
Swim-Induced Pulmonary Edema (SIPE)
Asthma
Hypothermia / Hyperthermia
Swim Combat / Exit Trauma
Anxiety
Corneal Abrasion

12. Swimming Induced Pulmonary Edema
Secondary Causes
•Wetsuit compression, compression calf/arm
•Pre Race hydration
•Stimulants
•Cold Water-Dive Reflex

13. • Compensatory Mechanisms:
– Shivering (which occurs from 37 to 32 degrees)
– Autonomic Nervous system (occurring from 37
to 32 degrees, includes bradycardia and
vasoconstriction)
– Extrapyramidal stimulation of skeletal muscles
– Adaptive Behavioral responses

14. TREATMENT
• Treatment: Focus on diminishing heat loss
• Use of heating devices. This includes
heaters within the tents , warm baths
• Removal of wet clothes. Wet clothing
leads to heat dissipation five times
• Cover and keep patient insulated.
Aluminum foil blankets efficient than wool
blankets
• Warm IV Fluids
• Serious hypothermia , follow Marine
Corps Marathon Hypothermia algorithm

15. 
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Head Injury
Fractures
Road Rash
Repetitive Motion
Medical Issues

16. 
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Cardiac Arrest, Heat Stroke, and ExerciseAssociated Hyponatremia.
Initial Approach to the unresponsive athlete:
Initial Evaluation (VS) / C-A-B
 Elevate the legs
 Assess Mental Status
 Assess Volume Status
 Fluid Replacement
 Continuous Monitoring


17. 
Initial Evaluation/ C-A-B
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Elevate the Legs
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AMS often presents with Heat Stroke and Exercise-Associated Hyponatremia
Assess Volume Status
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This will help any conscious athletes that are light-headed
Assess Mental Status
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Compressions-Airway-Breathing (check back of bib for Medical Information)
Fluids consumed, vomit/diarrhea, urinated during race, orthostatic pulse
Fluid Replacement
Fluids w/electrolytes such as Sports Drink or Chicken broth
 An IV may be started based on clinical judgment
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Continuous Monitoring
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Any athlete needing to go to the hospital MUST be seen by the Medical
Director

18. 
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Heat Exhaustion- more common in warmer environments
During race blood vessels maximally dilated in legs for cooling
and delivery of O2 to working muscles
Adrenaline released to regulate BP and maintain cardiac output
When athlete stops pump action is lost and adrenaline no longer
released
Vessels remain dilated leading to pooling of blood in lower
extremity
TREATMENT
Have athlete continue “cool down” walk after race
 Lie the athlete down and elevate the legs
 If no nausea present offer PO fluids or possible IV


19. 
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During exercise runners often sweat >1.5 L/Hr while maximally
absorbing approximately 1 L (negative fluid balance)
With as little as 3% loss of body weight a marathon runner
performance is impaired
Volume depletion leads to hyperthermia due to the limiting of
blood shunted to the skin
Runners present:
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Hypotension, tachycardia, weight loss, decreased skin turgor, hypernatremia
TREATMENT
Oral fluids such as sports drink or chicken broth
 IV NS, first w/500 ml bolus, then 500 ml over 30-60 min
 Any sign of AMS must have electrolytes drawn
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20. 
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Most common mechanism due to over-hydration
Trained athletes should have calculated fluid loss during exercise
Risk factors for developing EAH
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Finish under 4 hrs, inexperience, small stature, female gender
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Hallmark for EAH: AMS or unusual neurologic complaint
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Recognizing Hyponatremia
Stage 1: dizziness, nausea, vomiting, headache
 Stage 2: mental status changes (confusion, disorientation)
 Stage 3: altered consciousness (delirium, seizures, coma)

(Na+ 130-135 mEq/L)
(Na+ 125-130 mEq/L)
(Na+ <125 mEq/L)

21. 
Stage 1
If vitals stable, fluid restriction (4oz max) and observe until urination
 Fluid replacement: add 3 salt packs (3/8 tsp) to half cup electrolyte drink, this
will provide 1 g Na or a 3%saline solution
 Should athlete continue fluid restriction of 4oz max/ mile adding salt as above
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Stage 2/Stage 3
Consider transferring to ER
 Give 3% oral saline solution, if can tolerate PO fluids
 Transport via EMT/Paramedics, advise NO IV fluids until hyponatremia
excluded
 ALL runners w/EAH must receive discharge from Medical director


22. 
Stage 1
Draw blood for Na+ concentration and give no IV fluids
 Limit fluid to 4oz (preferably broth) or 3% saline or salty snacks
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Stage 2
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Draw blood for Na+ concentration, if >125 mEq/L offer PO broth
Oral hypertonic saline: 4 cubes of bouillon in 4oz hot water for a 9% solution
Limit fluid to 4oz, continue observation until they urinate
If not improved 15-20 min repeat oral solution or give 100 ml bolus 3%NaCl
Begin cardiac monitoring and pulse oximetry
A 2nd IV bolus given 10-15 min later
Any signs of neuro must go to ER, transport on IV=3%NaCl at 1 ml/min
Stage 3
Draw blood for Na+ concentration, if <125 or delirium present must go to ER
 Begin cardiac monitoring and pulse oximetry
 Give 100 ml bolus 3% NaCl and a 2nd in 10-15 min
 Both Valium and Ativan for IV injection are available to treat seizures


23. 
With a core temp >104°F organ/brain cells begin to die
Goal is Rapid cooling to < 104°F within 30 min
Athlete presents w/CNS changes, altered cognition/behavior
If oral reading >100.5°F, then rectal temp should be taken
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Early Warning signs
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Irritability, confusion, apathy, belligerence, emotional instability, irrational
behavior, giddiness , vomiting, numbness ,tingling, collapse, seizures, coma
 Paradoxical chills and goose bumps signal shutdown of peripheral circulation
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Follow Mantra: “cool first, transport second”

24. 
Cool First
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Rapid cooling by placing athlete into ice-water submersion tub (immerse trunk, both
arms and both legs) has 100% survival rate when athlete immersed within 10 min of
collapse (key to maximal cooling is constant stirring of the ice)
May also cold water douse the body while patient lying on porous stretcher, while
massaging major muscle groups w/ice bags
May also place wet ice towels over entire body, rotate w/cooler towels every 2 min
Check rectal temp/vitals/CNS status every few min
At athlete can be cooled from 108-110°F to 102°F within 15-30 min, average rate of
cooling drop is 1°F every 3 min
Transport Second
Once temp reaches 102°F, remove from immersion tub
 Observe for 30-60 min to ensure drinking fluids, normal vitals, good cognition
 Physicians recommended to follow up and evaluate patients w/sever hyperthermia
 If rectal cannot be measured, cold water immersion for 10-15 min then transport to
ER
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25. 
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Usually occurs near the finish, theory is increased adrenaline
release precipitates arrhythmia, when runner sees finish line and
sprints to improve position
Any athlete w/Cardiac arrest should prompt notification Medical
Command and activate 911 system and initiate ambulance
TREATMENT
Good quality chest compressions
 Early defibrillation when AED available
 Follow the Marine Corps Marathon algorithm for Emergency Cardiac Care


26. 1. 10.9 million runners, 59 (mean [±SD] age, 42±13 years; 51 men) had
cardiac arrest 0.54 per 100,000 participants; interval and among
(men 0.90 per 100,000, women 0.16).
2. Cardiovascular disease accounted for the majority of cardiac
arrests. The incidence rate was significantly higher during
marathons (1.01 per 100,000) than during half-marathons
3. Of the 59 cases of cardiac arrest, 42 (71%) were fatal (incidence,
0.39 per 100,000).
4. Among the 31 cases with complete clinical data, initiation of
bystander-administered cardiopulmonary resuscitation and an
underlying diagnosis other than hypertrophic cardiomyopathy
were the strongest predictors of survival.

27. 
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Most important factor pre-disposing to this condition is
hypovolemia
Damage to skeletal muscle and release CK-MM, myoglobin and
aldolase into circulation
High levels of myoglobin can cause acute renal failure, DIC, lactic
acidosis and cardiac dysrhythmias
Symptoms
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Risk Factors
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myalgias, muscular swelling, tenderness, dark colored urine, lower back or
abdominal pain
Poor fitness level, high temp/humidity, sickle cell trait, viral illness, hx of
myopathies, prior renal insufficiency
TREATMENT
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Fluid replacement, maintain good urine output, transport to Hospital

28. 
Check athlete for Hx of Diabetes
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Exercise acts like regular insulin and this must be calculated
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In non-diabetics may occur due to complete depletion of glycogen stores
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Symptoms
Fatigue, dizziness, tachycardia, nausea, vomiting, impaired mental status
 *Any of these symptoms a “finger stick” glucose should be checked
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TREATMENT (if glucose <55)
PO glucose if no nausea or vomiting
 Bolus of D50 IV
 ER transport for those who fail to respond or remain hypoglycemic


29. 
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Exercise=Sympathetic Nervous System
Digestion= Parasympathetic Nervous System
Athletes must train their guts to digest on the run
Under ideal conditions the gut can process 1.5 L/hr
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Many novice runners will over-feed or over-hydrate, and gut cannot handle
this volume leading to nausea/vomit
Symptoms
Diarrhea (possible osmotic diarrhea), nausea, vomit, abdominal pain
 *Be cautious w/abdominal pain, during exercise 70% of splanchnic circulation
is shunted to working muscles, this can result in ischemia and eventually
necrosis of intestinal lining cells


30. 
15% of general population and 40% athletes w/allergies will
develop Exercise-Induced bronchospasm
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If patient has true asthma, number rises to over 70%
Common on days w/ increased pollutants such as smoke, dust,
pollen
TREATMENT
Replacing volume, administer breathing treatments w/inhaled bronchodilators
 Albuterol is effective as rescue inhaler


31. 
Treatment is two fold: addressing metabolic issues and
mechanical stretching of injured muscle
First begin IV and check serum sodium and magnesium
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TREATMENT
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EAH? Draw iSTAT
2-4 g Magnesium sulfate give slow IV push while watching reflexes and
respirations
Ativan 0.5 mg IM or IV
2-4 g Magnesium sulfate can be added to 1 L IV NS and run at 500-1,000 ml/hr
Sickle cell trait can produce muscle ischemia and should be treated w/O2 and
IV fluids, transport to ER
Use of the Massage therapist may be helpful

32. 
Remember sunburned skin does not sweat well, SPF >30 should be
used
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Abrasions should be cleaned w/Hydrogen peroxide or Hibiclens
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Avoid waterproof products which block pores and reduce sweating
Betadyne retards wound healing
Small, intact blisters that are minimally painful usually don’t need
any treatment. Cover it with a small bandaid, and triple antibiotic
ointment.
Larger or painful blisters that are intact should be carefully drained,
without removing the skin.
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clean the skin over the blister with rubbing alcohol or soap and water.
sterilized needle or pin, puncture a small hole at the edge of the blister.
Drain the fluid with gentle pressure and apply a bandaid with some triple antibiotic
ointment.
Keep it clean and dry for 2-3 days, changing the dressing daily. You may then begin
to carefully trim away the dead skin. Use second skin, or blister pads for protection,
until the new skin matures.

33. 
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TIME IN: ____________ TIME OUT: ___________
Arrived from:
Ambulance
Massage Finish Line
___________________________
Finisher?
Yes
No
DQ?
CHIEF COMPLAINT
Altered Mental Status Seizures
Short of Breath
Vomiting
Diarrhea
ABD Cramps
Dizziness
Syncope
Nausea
Headache Trauma
_______________
PHYSICAL FINIDINGS
Dehydration
Edema
Confusion
Hyperthermia
Other _____________________________
DIAGNOSIS
Exhaustion
Trauma
Other
Yes
No
Exhaustion
Muscle Cramps
Other
Hypotension
Hypothermia
Dehydration
Hyponatremia
Hyperthermia
Hypothermia
Other -_____________________________
OUTCOME
Resume Race
Discharge 
Transport to Hospital
COMMENTS
__________________________________________________________________________________________
___________
M.D. ______________________________________________
R.N.
___________________________________________________

34. HOME CARE
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Stretch tight muscles, and ice sore tendons and joints.
Anti-inflammatory medications, such as ibuprofen or
naproxen may help speed recovery.
Eat a light diet with foods that are easy to digest, such
as pasta, rice, or potatoes. Adding some protein
actually helps your muscles recovers faster.
Drink plenty of fluids. It is a good idea to salt your
food or use a Sports Drink to replace the electrolytes
(such as sodium) you have lost. Avoid drinking large
quantities of water.

35. SEEK MEDICAL ATTENTION IF YOU EXPERIENCE:
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Severe leg or calf pain not improved with elevation
Abdominal pain with or without vomiting or diarrhea
Persistent temperature over 100.50 F (37.80 C) orally
Blood in vomit or stool (even dark red or black stool)
Unusual weakness, dizziness or fainting
Decreased urine output, bloody or very dark urine
Unusual chest pain, muscle cramping or edema
[puffiness]
Coughing, trouble breathing, colored or bloody
phlegm
Severe headache, vision changes or confusion