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Optimizing Marathon Race Safety Using an
Incident Command Post Strategy
Katherine V. Yao, MD1; Christopher Troyanos, ATC2; Pierre D’Hemecourt, MD, FACSM3;
and William O. Roberts, MD, MS, FACSM4
Mass participation events including marathons and shorter
road races, Nordic ski, bicycle, and triathlon competitions
have been gaining unprecedented popularity with increasing participation in the United States. Running USA reports
more than 17 million total finishers in road races across the
United States in 2015 with more than 500,000 of those finishes in marathon races (1). The three largest marathons in
the United States are the New York City, Chicago, and Boston
Marathons, which in 2015 combined for approximately
113,000 finishers and close to 50,000 finishers in the New
York City Marathon alone (1). As road racing participation
continues to grow in popularity, the medical organization of
these mass participation events must evolve to accommodate
the growth. Participant safety, injury prevention, and medical
treatment have always been at the forefront of race planning
and medical preparation. The unfortunate Boston Marathon
bombings in 2013 highlighted the large-scale public safety
concerns that also must be addressed when planning a mass
participation event. Marathon and other large sport events
now require integration of local, regional, and federal agencies with use of public and private resources, and must follow
regional and federal emergency protocol guidelines to optimize safety for the participants and the public. Public safety
must be integrated into the management plan of large races
and events as the potential for mass casualty events often
hinges on the evolution of global and international relations. Our goal is to share the components required to
prepare for a large marathon race using a unified command
structure to reduce injuries, treat medical conditions with
best practice guidelines, avoid hospital overload, and reduce
the threat to public safety.
Boston Children’s Hospital, Boston, MA; 2Sports Medicine Consultants,
LLC Norfolk, VA; 3Boston Children’s Hospital, Newton, MA; 4UMN Phalen
Village Clinic St. Paul, MN
Address for correspondence: Pierre Allou d’Hemecourt, MD, FACSM,
Boston Children’s Hospital Newton, MA; E-mail:
Current Sports Medicine Reports
Copyright * 2017 by the American College of Sports Medicine
Volume 16 & Number 3 & May/June 2017
Mass Casualty Incident
A mass casualty incident is defined as an event which
generates more patients at one time than locally available
resources can manage using routine procedures (2). Marathon
race management structure must be organized to reduce the
likelihood of a mass casualty incident and avoid overwhelming
the resources of the local emergency medical services (EMS)
providers and hospitals. Large race organizations, such as the
Boston Athletic Association, responsible for organizing the
Boston Marathon and other Boston area road races, and other
race organizations in other regions of the country regularly
use the National Incident Management System (NIMS) and
Incident Command System to build their command center
infrastructure (3).
The Incident Command System was initially developed in
the mid 1970s to coordinate the large number of resources
required to manage massive wild fires in California. For many
years, the fire service used some version of an Incident Command System to mitigate logistical and personnel problems,
but there was never a formal system in place to manage multiple agencies. The dreadful experience of September 11, 2001,
changed the landscape, and the U.S. government realized a
unified system was essential to coordinate multiple agencies from different jurisdictions to implement an effective
emergency response.
Under directives (Homeland Security Department 5 and 8)
authorized by President George W. Bush, the NIMS system
was created after the terrorist attacks of September 11. The
Homeland Security Act of 2002 sanctioned the U.S. Homeland Security Department to further develop NIMS and set
up the laws and regulations that are now in place for managing domestic incidents. The system is meant to guide a
proactive approach to manage all threats and hazards regardless of cause, size, location, or complexity to reduce loss
of life, property, and harm to the environment. It is intended
for use by individuals, communities, and organizations in
both the private and nonprofit sectors (4). The ramp up of
NIMS created ten federal office locations to manage regional
events throughout the United States (5). The most significant
difference between the old and new NIMS formats was the
recognition that emergency responders were not the only
personnel needed in a mass casualty incident, and many
agencies play a role in pre-event planning for potential targets
and threats.
Marathon as a Command Post
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
The incident command system provides a structure within
NIMS to integrate a combination of facilities, equipment,
personnel, procedures, and communications usually housed
in separate organizations. The incident command group
facilitates the five major functional response areas including command, operations, planning, logistics, intelligence
and investigations, finance, and administration, enabling incident managers to focus on key concerns without sacrificing attention to any component of the command system.
In the application of this system for marathon race planning, there must be effective and efficient integration of
all public safety agencies, EMS, hospitals and emergency
departments, personnel including medical staff and EMS
personnel, and equipment management (6).
Integration of Public and Private Safety Agencies
A marathon should be planned as a potential mass casualty event to ensure appropriate resources are available to
react to any threats that may arise. Medical, emergency, and
security teams must develop a comprehensive plan to ensure
quality medical care and optimal safety on race day. Community, state, and federal agencies should be involved in the
planning. Local hospitals should be informed so they can
coordinate their staffing and resources and develop triage
and treatment protocols for race day. For example, in Boston, the Massachusetts Emergency Management Agency
(MEMA) coordinates the preparation of federal, state, local
government, and private agencies to respond to potential
state emergencies and disasters (7). MEMA assists with
planning the Boston Marathon by coordinating the regulatory
and health systems across Massachusetts cities and towns.
At planned meetings for local, state, and federal agencies,
theoretical marathon disasters are discussed to brainstorm
action plans for each potential scenario. The Boston Athletic
Association, which organizes the Boston Marathon, optimizes public safety by building strong relationships and
working closely with the fire department, local and state
police, the Department of Public Health, and MEMA. These
groups collaborate to develop comprehensive policy and
operational plans that define their roles so the necessary
resources can respond efficiently and effectively to any
potential threat. Within the leadership group, there should
be designated race managers who are aware of the higher
level plan protocols and can activate an emergency response.
While most volunteers and division leaders will not know the
full details of the highest level plan protocols, all volunteers,
division leaders, and medical directors should have easy access
to the point persons responsible for activating an emergency
response for actual or potential threats.
Understanding Local Race Factors
There are several factors that affect racers, injury rates,
and the ability to respond to emergencies which vary from
race to race. Major issues to consider are the weather, altitude,
concurrent regional events, course terrain, course layout and
distance, volume of runners, fitness levels of the participants,
and acclimatization that may be required.
Race day weather is the most likely factor to affect runner
outcomes with slower pace, increased medical encounters, and
increased participant drop outs. Timing of the race in relation
to the geographic location is an important consideration when
planning the date of the race. For Northeast and Midwest
locations in the United States, such as Boston, New York, and
Chicago, the spring and fall seasons are more likely to deliver
good running conditions and avoid extreme heat and cold,
while winter season may be better in the south and on the
west coast. However, outlier weather conditions may occur,
so it is necessary to continuously monitor weather forecasts leading up to the race. The wet bulb globe temperature (WBGT) correlates with the risk of exercise based on
environmental conditions and should be used to help determine race policies. It is calculated with the equation: WBGT =
0.7 (wet-bulb temperature) + 0.2 (black-globe temperature) + 0.01 (dry-bulb temperature) (8), and the water
content of the air is the major variable affecting heat transfer
during exercise. The American College of Sports Medicine
defines low-risk WBGT to be less than 65-F (18.3-C),
moderate risk between 65.1-F and 72.0-F (18.4Y22.2-C),
high risk for all competitors between 72.1-F and 82.0-F
(22.3Y27.8-C), and extreme risk and recommendation for
event cancellation at temperatures of 82.1-F (27.9-C) or
higher (8). However, these WBGT levels are based on acclimated, fit young men and not the usual participant
profile of a marathon. Although WBGT is used widely and
adopted by many sports federations, it may underestimate
heat stress risk when sweat evaporation is restricted under
high humidity conditions (9), and humidity adjustment
scales have been created to accommodate for high humidity weather (10,11). It is important to monitor the
weather forecast because weather can significantly impact
the number and severity of injuries and visits to the medical tent. The Boston Marathon heat wave in 2004 led to
an increase in number of visits to the medical tents from
its typical 2% to 4% of all runners to nearly 10% of all
runners due to the unusually hot weather with temperatures reaching 86-F at the finish line (12). Races should
account for increased numbers of nonfinishers both on
the course and at the finish line if there is elevated WBGT
on race day (13) and consider establishing a ‘‘do not
start’’ WBGT level (14) based on the race’s capabilities
of handling the anticipated volume of nonfinishers and
medical encounters.
Heat and acclimatization
Acclimatization to different weather and geographical
conditions is another factor in race outcomes. Participants
should be educated about proper heat acclimatization recommendations if they are preparing for a race with higher
temperatures and humidity than the area where they live.
Although some temperature adaptations develop within
the first week of training in the heat, it may require 6 to
10 d to achieve near complete cardiovascular and sudomotor adaptations, and a full 2 wk to optimize aerobic
performance in hot ambient conditions (11,15,16). Highly
trained athletes typically adapt more quickly than untrained
or lesser trained individuals (17,18). A comprehensive emergency action plan for exertional heat stroke (EHS) with
sufficient numbers of trained staff and on-site equipment for body temperature measurement and wholebody rapid cooling of athletes is required for all races
as EHS can occur in very temperate conditions. Race
planners also should consider scheduling races to start
Current Sports Medicine Reports
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
near sunrise to limit the exposure of participants to the
hottest part of the day and to avoid midday heat in hot and
humid environments.
The physiological effects of cold acclimatization in athletes are typically negligible for nonarctic conditions. Participants preparing for races in cold temperatures should be
educated about proper race clothing with multiple removable layers. The medical team should have the medical resources to treat hypothermia, and if in deep cold, frostbite.
Heated medical tents or shelters at medical treatment locations should be available. The increased ventilation of exercise in cold and dry environments results in airway drying and
inflammation, which can exacerbate pulmonary conditions.
Racing in these conditions may increase asthma exacerbations and cause exercise-induced bronchospasm in athletes
who have no problems in warm conditions. Medical teams
must be prepared to treat with nebulized bronchodilators,
humidified air, and oxygen. The International Olympic Committee Consensus Statement on thermoregulation suggests
that elite athlete competitions not start or continue with a
combination of air temperature and wind speed (wind-chill)
colder than j16.6-F (j27-C) (19).
Events held in high altitude environments 1500 to 3500 m
(4900 to 11,500 ft.) require more participant education and
planning. There are very few events conducted at altitudes
above 3500 m other than the Leadville 100 that peaks at
4019 m. High-altitude environments have lower partial
pressure of oxygen which causes alterations in physiologic functions associated with exercise. The physiologic
responses and clinical symptoms of altitude illness begin
to play a role in exercise performance and acute mountain sickness at 1500 m (4900 ft.) and become more prominent at moderate elevations greater than 2500 m (8200 ft.)
(20). Acute exposure to altitude first leads to an increased
ventilation rate causing a respiratory alkalosis and a resulting diuresis mediated by the renal system. This triggers other
complex physiologic changes, all of which reduce endurance exercise performance. This altitude-induced diuresis
occurs as an early stage of acclimatization within 12 to
24 hours of exposure and athletes should be aware of
this to maintain a good hydration status (20,21). Medical
staff and participants should be educated about altitude illness symptoms to monitor for including headache, nausea,
vomiting, dizziness, weakness, anorexia, insomnia, dyspnea
at rest, cough, decreased exercise performance, and the more
severe symptoms of changes in mental status, ataxia, tachycardia, rales, wheezing, and chest tightness/pain. Organizers
should consider special monitoring for populations at higher
risk of altitude sickness, including obese, older, and pregnant
individuals, younger children, and those with preexisting lung
disease, anemia, and sickle-cell disease. In preparation for
racing at high altitude, arriving about 2 wk before competition should allow time for acclimatization (19). For
altitude sickness prevention, controlled ascent, acetazolamide, and, in certain cases, dexamethasone may be used (20).
To treat symptomatic racers, medical teams should have
proper resources including appropriately trained staff
and sufficient supplies including medications and supplemental oxygen. If rapid transport to lower altitudes will
not be possible, a Gamow bag should be included in the
response kit.
Volume 16 & Number 3 & May/June 2017
Course layout and difficulty levels
When organizing the medical plan for a marathon race,
the overall difficulty level of the race course and specific
areas of challenging terrain must be considered. Hills increase the exertion required for runners and steep or long
elevation changes may require specific medical tents and
resources to care for those who are overly stressed by large
elevation climbs. Course loops may require direction aids
for the racers to ensure they follow the correct path at the
intersections. These loop intersections also are ideal placements for medical stations because the higher foot traffic
allows a greater opportunity to intercept injured runners as
they pass these sites. Organizers should monitor road conditions and remove any hazardous elements if possible. In
rainy or wet conditions, racers should be alerted about areas
with slippery or rough terrain and medical staff should be
readily available at those sites.
Volume of runners
The large volume of runners in marathon races and the
associated spectators puts these events at higher risk of
being singled out as a target for terrorist activity or demonstrations that increase the possibility of becoming a
mass casualty event. When organizing a race, one must
consider the expected volume of runners and spectators
and enlist trained staff to control anticipated crowds throughout the event. The volume of racers also will dictate the
number of medical staff and the amount of supplies required to safely conduct the event. Organizers should estimate when the largest group of runners (surge volume) will
be in critical areas of the course and at the finish line to
adequately staff the areas to control the spectators and
provide medical care for injured runners. Large volumes of
runners and mass crowds magnify the need for a chain of
command that is understood by all staff to properly execute
emergency protocols.
Fitness levels of participants
Each race is characterized by the number of participants
and the range of fitness levels of its participants. The type of
athletes participating in the event will influence the medical
outcomes and organizational needs of the race. An exclusively elite competition will need a different allocation of
resources than an event that requires previous performance
qualifications to participate or a race with a mixture of all
competitor levels. All races should be prepared for cardiac
arrests, and events with a mixture of competitors with
varying fitness levels will likely have more running injuries
and overexertional outcomes that must be factored into the
medical plan. Defibrillators and ACLS trained teams should
be readily available for any potential cardiac events at all
races. For races with high potential drop-out rates along the
course, there should be a sweep system to transport racers
to the finish line or meeting areas.
Volunteer Preparation and Education
A large task for the marathon organization is recruiting
and organizing volunteers. It is almost impossible to host a
large marathon race without the goodwill of volunteers,
and it is vital to recruit qualified volunteer staff. The volunteers need appropriate education for the jobs they will be
Marathon as a Command Post
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
assigned on race day. It is beneficial to have a diverse group
of medical volunteers including medical doctors, physician
assistants, nurses (especially critical care and emergency
department), nurse practitioners, physical therapists, athletic trainers, paramedics, and EMT. Podiatrists and massage therapists can be useful adjuncts to the medical team.
Medical volunteers may be recruited from local hospitals
and various organizations like the American Red Cross, the
Medical Reserve Corps, the EMS community, the athletic
trainer communities, amateur radio clubs, and from former
volunteer staff.
The volunteer medical staff is often split into subsections or divisions. The leadership team includes the medical directors, communications leaders, and subsection or
division leaders of the medical staff. The medical staff is
often divided by professional backgrounds (MD/DO, RN,
EMT, PT, DPM, PA, ATC, and so on), EMS coordinators,
medical record leaders, medical security leaders, leaders in
charge of the start and finish line areas, medical course tent
organizational leaders, and family relations leaders. The
division heads should meet starting several months before
the race and integrate into the race structure. Local EMS
groups in local hospitals and area emergency departments
should be informed of the race plans for medical emergencies
and be involved in the race planning when appropriate.
Medical volunteer staff education is a critical part of
preparation. Medical protocols should be reviewed at larger
medical volunteer meetings and videos should be provided
for those who are unable to attend. The education is usually
delivered with a combination of videos, medical meetings,
written materials, and web site information. The education
should include recognition and treatment of common race
injuries, medical problems unique to endurance events, and
medical emergencies along with the treatment protocols and
emergency response protocols that are used by the race.
High-yield topics include exertional heat illness, exerciseassociated collapse, exercise-associated hyponatremia, and
sudden cardiac arrest in runners. Regional emergency departments should be educated to recognize and treat hyperthermia (EHS) and exercise-associated hyponatremia in a
timely manner. Medical providers should be briefed on the
expected medical supplies and equipment that will be
available for use and made aware of the limitations of the
available equipment so that patients may be transferred to a
higher level of care when their illnesses fall beyond the
medical tent capabilities.
Planning for medical volunteer placement, allocating medical equipment, and delivering supplies to the proper area also
are essential. Anticipating the surge capacity of each medical
site as racers pass through different sections of the course optimizes the care of runners in predetermined areas of increased
course difficulty. Larger allocation of staff and equipment
should be supplied to larger foot traffic areas, such as the finish
line, loop intersections, and areas of anticipated increased
course difficulty. The types of medical supplies needed for
optimal care should be determined and ordered several
months ahead of the race. Organizers should have a team in
charge of medical supply logistics and distribution to appropriate medical treatment sites. There should be a communication and transport system in place to allow for relocation
and delivery of supplies during the race to locations in need.
An emerging and vital topic of education for all race
volunteers and medical staff is the understanding of ‘‘scene
safety.’’ Though compassion comes naturally to race volunteers and medical providers rush to aid anyone in need,
volunteers must always first assure that the sites they are
servicing are secured and safe before attending to others.
The race response protocol must be emphasized during the
education and preparation of all volunteer staff. Race organizers have the responsibility to ensure the safety of their
workers and volunteers, in addition to the safety of the
racers and the public. Again, the terrible Boston Marathon
bombings in 2013 reemphasized the importance of assuring scene safety. Many volunteers placed their lives and safety
at risk rushing to the aid of injured runners and spectators
before the area was secured and before a third bomb was
discovered and removed from the site. It was only luck that
the third bomb was faulty and did not detonate. The importance of scene safety and personal safety cannot be overemphasized and should be applied across all spectrums of
threats from weather to illness and to terrorism. Staff and
volunteers should be educated to recognize threats and to
remove themselves from any situation that may put their own
health and safety at risk.
Dividing the Course Coverage Locations
Medical tent placement recommendations include tents
traditionally set at the finish line and at several locations
throughout the course. Loop intersections where the course
might circle around to intersect at one point are typically
good areas to set up medical tents due to the higher number
of runners moving past those points. Areas of harsher terrain and large hills should have medical providers available.
Race organizers should identify areas on the course that
narrow the racing area and concentrate runner traffic and
potential regions of the course that limit emergency vehicle
access. For these crowded and less accessible areas, there
should be designated EMS access and egress points in cases
of emergencies. There should be designated prearranged
points to transport people who are intercepted along the
course for care and designated medical tents or ambulances
to transport those requiring specialty care.
Water, electrolyte water/juices, and basic medical supplies
should be available in the comfort care medical stations.
Major medical tents, typically those at the finish line and
high medical encounter areas, should have IV capacity,
heating and cooling capacity, ALS capabilities, and ambulances. Medical staff should know which locations have
advanced care capability, so patients are transported to the
appropriate locations. All medical tents should be supplied
with an automated external defibrillator. There should be
medical supply vehicles available to replenish supplies at the
medical stations. EMS should be readily available with ambulances stationed at set locations along the course or moving
along the course, and at the finish line. A system should be
established to transport runners who drop out of the race to
preset common meeting areas. There should be set diversion
locations to transport runners and the public as part of the incident command system should there be any threat to public and
race safety (bombing, fire, vehicle accident). Mobile hazmat
and reserve ambulances may be considered for any large race
Current Sports Medicine Reports
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
with potential mass casualty incident or threat that requires
those services.
coordination with the public and private sectors to provide
mental health support to large groups of volunteers.
Multiple lines of communication are recommended for
management during a race. There should be a common medical command center in place organizing communication between sites and divisions. It is helpful to use more than one
communication system including a combination of handheld
radios and cell phones. A common communication system,
including at least one that is not reliant on the national cell
phone tower grid, should be used between the race organizers
and the division leaders, such as handheld radios. An emergency text message system that can be sent from a single source
is valuable for transmitting information to all staff and volunteers. There are many reasons and causes for failed communication lines, most commonly overwhelming the cell
phone capacity due to large volume use during the event. In
instances of public safety concern, police or federal officials
may prohibit certain radio or cell phone use. Race organizers
should be prepared with multiple modes of communication
should one or several systems be taken out of service for any
reason. Clear communication pathways should be set up between course medical tents, sweep buses, finish line areas, and
EMS. The communication infrastructure should follow the
incident command structure.
Marathon and other road races are popular events in the
United States with record participation that inspire people
to pursue physical activity and are an opportunity for
personal growth and accomplishment. However, the wide
attention and large participation may make some events
targets for terrorist attacks with the risk of mass casualties
beyond the usual medical encounter level of the event. Race
organizers should establish a chain of command modeled on
the NIMS and the Incident Command System to improve
event safety and help communities practice for mass casualty
events. Organizers should address local risk factors, educate
and allocate volunteers appropriately, and divide the course
and medical resources in a well-organized manner with open
communication lines. There are additional resources for those
interested in race medicine and more information that can be
obtained through local race organizations and the International Institute for Race Medicine (22).
Injury Reduction
Education for injury reduction should be provided to all
medical volunteers and event participants. Education for
volunteer staff may be provided in informational sessions
and videos to recognize potential injuries and medical complications of race participation. Injury prevention information is most effectively distributed to participants online
through the race organization’s web site, targeted emails,
and social media. This should include information early in
the training as well as emails in the days leading up to the
event discussing weather conditions and health recommendations. Some high yield topics include proper training
methods, common race injuries, preparing for hot and cold
race conditions, hydration strategies, and strategies to avoid
hyponatremia due to fluid overload. Runners should be made
aware of red flag symptoms that may cause problems during
endurance events. For instance, fever and viral respiratory
tract infection in the week leading up to the event are associated with EHS and reasons not to start the race. Runners
should be made aware of the cardiovascular risks of running
and associated risk factors for sudden cardiac arrest during
these events. Finally, runners should be aware of the impact of
weather conditions on race safety and any race day flag systems or warning systems in use to inform participants of
event modifications, cancellation, or emergencies.
Mental Health Support
Finally, it is important to recognize the importance of
providing mental health support for racers, volunteers, and
staff for a traumatic event affecting an individual (race related death) or a large-scale catastrophe (bombing with or
without casualties). The race organization should be prepared to identify those in need of mental health support and
be able to provide care to those in need. This may require
Volume 16 & Number 3 & May/June 2017
The authors declare no conflict of interest and do not
have any financial disclosures.
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