On-site Medical Team Research Articles

Advanced nurse practitioners- the missing link on old age pyschiatry inpatient wards?

Aims1. This project aimed to review the medical cover available to an Old Age Psychiatry inpatient ward.2. To discuss with ward staff their view for potential improvements and areas of clinical development.3. To review the potential of a Full Time Nurse Practitioner role on the ward.One junior doctor (CT1 or equivalent) was allocated to cover the ward whilst balancing their other training needs and clinical commitments. The inpatient ward was based in a community hospital with no onsite medical team. The patients mostly had complex medical needs and multiple comorbidities.MethodThe Junior Doctor's timetable and the time allocated to the ward was reviewed. Questionnaires were conducted with nursing staff to assess their views on the support of physical health cover. The patient notes were analysed for the time taken to review patients after falls over a one month period.ResultThere were 14.5hours allocated to ward cover. An additional 4 hours was provided by another visiting junior doctor totalling 18.5hours per week- 11% of the time. This figure does not account for annual leave, on call commitments or study days whereby there was no additional cover.A short survey completed by ward staff showed- (1 = Very Poor/Difficult 5 = Excellent/Easy) •They rated medical cover of physical health needs on ward 7 as 1.3.•They found contacting a Doctor to discuss a physical problem as 1.7- with particular concern for OOH.•It was rated to be extremely difficult for a same day review of physical health problems- 1.7•It was rated extremely difficult to get a physical review following a fall on ward 7- 1.4•Continuity of care for the patients on ward 7 was rated as 1.6.The patient case files reviewed over a one month period showed x8 falls. These took on average 14 hours before having a review.ConclusionMedical cover for the old age psychiatry inpatient ward was inconsistent and a challenge for a single trainee to manage alongside their other clinical commitments and training needs. A case was proposed to management with an SBAR for a Full Time Advanced Nurse Practitioner which has been approved. This role should provide patients with appropriate cover of their physical health needs. It will allow the junior doctor to work alongside them on the ward supporting each other to provide optimal care for the inpatients.

Collaborative Relationships for Mass Gathering Events

Introduction:Electronic Dance Music events (EDMs) are complex mass gatherings and given published rates of illnesses, injuries, and hospitalizations, these events can place an additional burden on local health care services. Accordingly, during the planning process for EDMs many stakeholders are involved; however, local hospitals, a key part of the medical safety plan, are often excluded. In this case report, it is posited that the involvement of local hospital(s) and the resulting integration of on-site and acute-care service provision during an event, ultimately reduces the burden placed on local hospitals.Methods:Case report; synthesis of published literature.Results:A 25,000 person per day, two-day mass gathering EDM event trialed a model of collaborative planning with a local community hospital. Planning included the identification of a hospital liaison, pre-event teleconferences between event staff, contracted and public medical response teams, emergency management teams, harm reduction practitioners, public health, and hospital personnel. Throughout the collaborative planning process, vital information was shared in order to optimize patient continuity of care and streamline the transition of care from site medical response to an acute care setting. Outcomes included the prevention of unnecessary transfers to the hospital; however, those patients who required transfer had their initial treatment started prior to leaving the venue. Further, collaborative planning also contributed to improved bidirectional data sharing to better understand the impact on the local hospital of the event, including transfers from the onsite medical team as well as transports from the community and self-presentations for care.Discussion:The collaboration of onsite medical and hospital teams improved the delivery of essential medical care to the patrons of the event and added a layer to the safety planning process essential to mass gathering events.

On the Way Out: An Analysis of Patient Transfers from Four, Large-Scale, North American Music Festivals Over Two Years

Introduction:Music festivals are globally attended events that bring together performers and fans for a defined period of time. These festivals often have onsite medical care to help reduce the impact on local healthcare systems. Historically, the literature suggests that patient transfers offsite are frequently related to complications of substance use. However, there is a gap in understanding as to why patients are transferred to a hospital when an onsite medical team, providing a higher level of care (HLC), is present.Aim:To better understand the causes that necessitate patient transportation to the hospital during festivals that have onsite physician-led coverage.Methods:De-identified patient data from a convenience sample of four, large-scale Canadian festivals (over two years) were extracted. Patient encounters that resulted in transfers to hospital, by ambulance, non-emergency transport vehicle (NETV), or self-transportation were analyzed for this study.Results:Each festival had an onsite medical team that included physicians, nurses, and paramedics. During 34 event days, there were 10,406 patient encounters, resulting in 156 patients requiring transfer to a hospital. A patient presentation rate of 16.5/1,000 was observed. The ambulance transfer rate was 0.12/1,000 of attendees. The most common reason for transport was musculoskeletal injuries (54%) that required imaging.Discussion:The presence of onsite teams capable of treating and releasing patients impacted the case mix of patients transferred to a hospital, and may reduce the number of transfers for intoxication. Confounding preconceptions, patients in the present study were transferred largely for injuries that required imaging. Results suggest that a better understanding of the specific effects onsite medical teams have on avoiding off-site transfers will aid in improving planning for music festivals. Findings also identify areas for further improvement in care, such as onsite radiology, which could potentially further reduce the impact of music festivals on local health services.

Measuring the Masses: Guidelines for Publication of Case Reports on Mass Gatherings

Introduction:The science supporting event medicine is growing rapidly. In order to improve the ability of researchers to access event data and improve the quality of publishing mass gathering cases, it would be of benefit to standardize event reports to permit the comparison of similar events across local and national boundaries. These data would support the development of practice standards across settings.Aim:The authors propose the creation of a publication guideline to support authors seeking to publish in this field.Method: Derivation study via analysis of published case reports using the Delphi process.Results:Data elements were inconsistently reported within published case reports. Categories of variables included: event demographics (descriptors of date, time, genre, activity, risks), attendance and population demographics, data related to climate and weather conditions, composition and deployment of an onsite medical team, highest level of care available onsite, patient demographics, patient presentations and measures of impact on the local health care system such as transfer to hospital rates. Of note, there was a high incidence of “missing” variables that would be of central interest to researchers.Discussion:Approaches to standardizing the collection and reporting of data are often discussed in the health care literature. The benefits of consistent, structured data collection are well understood. In the context of mass gathering event case reporting, the time is ripe for the introduction of a guideline (with accompanying guidance notes and dictionary). The proposed guideline requires the input of subject matter experts (in progress) to enhances its relevance and uptake. This work is timely as there is ongoing work on improving an international event medicine registry. If the evolution of both proceeds in lockstep, there is a good chance that access to a rigorous data set will become a reality.

This is Sparta - A Five-Year Obstacle Course Racing Injury Analysis

Introduction:Obstacle Course Races (OCR) are mass participation sporting events, challenging participants to complete physical and mental tasks over a variety of distances and terrains. The case series studied, Spartan Race, has races occurring in urban, rural, and wilderness venues, ranging from 5 to 42 kilometers, while incorporating 20 to 60 obstacles.Aim:To understand the injury rates, injury and illness patterns, and transport considerations within OCRs.Methods:A secondary data analysis of de-identified medical charts from 56 Spartan Race events occurring in Eastern Canada from 2014 to 2018 was performed. The scope of practice was first aid from 2014 to 2017, with the addition of advanced life support onsite in 2018.Results:Over 5 years, 2,387 injuries occurred among 127,481 participants, creating a patient presentation rate of 18.7/1000. Although the majority of injuries (92%; n=2,204) were treated onsite, a transport to hospital rate of 1.2/1000 (n=154) occurred along with an ambulance transport rate of 0.23/1000 (n=29). Lacerations (55%) and musculoskeletal (36%) injuries were the most frequent clinical presentations observed, whereas life-threatening emergencies (affecting airway, breathing, and circulation) were infrequent (n=10). Transport to the closest local tertiary care center was on average 49.8 kilometers (25.3 kilometers) and 40.5 minutes (17.9 minutes) away from the venue.Discussion:These results suggest that there may be an upper limit to the injury rates within Spartan Races. The majority of patient presentations were able to be treated onsite, supporting the need for a qualified onsite medical team to mitigate the strain on local healthcare systems. Although life-threatening emergencies were uncommon, they do occur, and medical teams must be appropriately prepared. Further research is needed to understand the staffing and equipment requirements of medical teams, the demographic information of the injured, and the examination of the impact OCR events have on the local health care systems.

Perspective of an Academic Consortium for Preparedness of Emergency/Disaster Medical Response during 2020 Tokyo Olympic/Paralympic Games

Introduction:A large number of visitors to Tokyo during the Tokyo Olympic and Paralympic Games in 2020 resulted in an increase of injury/illness and burden to the routine emergency medical services system. Furthermore, extremely hot and humid weather, terrorism, and outbreaks of infectious diseases are marked risks.Aim:We introduce the present status of an academic consortium (AC2020) to fulfill our mission as academic organizations. The Japanese Association for Acute Medicine (JAAM) and six academic associations have initially established the AC2020 since 2016, which consists of the 23 associations at this time. The role of the AC2020 is to provide knowledgeable evidence, intelligence, and support for constructing response plans for medical problems via the website (http://2020ac.com/).Methods:The joint committee of the AC2020 (JC-AC2020) has been launched to accomplish consortium activities; make statements and recommendations, compile manuals, conduct seminars, and coordinate the training program of on-site medical teams. The JC-AC2020 organizes nine working groups of heat stroke, lightning strike, nursing, athletes, first responders, foreigners, pre and in-hospital response of MCI, and data collection for audit.Results:As of December in 2018, AC2020 has released 30 documents and 10 event-news on the website including seven statements, two recommendations of a prerequisite of the on-site medical team, and two manuals concerning the treatment of gunshot and explosive injuries. Based on some of these statements, the Tokyo government has already enhanced the previous plan.Discussion:The AC2020 will propose the web site as a portal site and platform, disseminate the activities widely to society, and ask for the cooperation of other related organizations and academic societies. The AC2020 will aim to provide the landmark project of mass-gathering medical care in Japan as well as the transition to the Olympic Games in Paris in 2024.

On the Way Out: An Analysis of Patient Transfers from Four Large-Scale North American Music Festivals Over Two Years.

Music festivals are globally attended events that bring together performers and fans for a defined period of time. These festivals often have on-site medical care to help reduce the impact on local health care systems. Historically, the literature suggests that patient transfers off-site are frequently related to complications of substance use. However, there is a gap in understanding why patients are transferred to hospital when an on-site medical team, capable of providing first aid services blended with a higher level of care (HLC) team, is present. The purpose of this study is to better understand patterns of injuries and illnesses that necessitate transfer when physician-led HLC teams are accessible on-site. This is a prospective, descriptive case series analyzing patient encounter documentation from four large-scale, North American, multi-day music festivals. On-site medical teams that included HLC team members were present for the duration of each festival, so every team was able to "treat and release" when clinically appropriate. Over the course of the combined 34 event days, there were 10,406 patient encounters resulting in 156 individuals being transferred off-site for assessment, diagnostic testing, and/or treatment. A minority of patients seen were transferred off-site (1.5%). The patient presentation rate (PPR) was 16.5/1,000. The ambulance transfer rate (ATR) was 0.12/1,000 attendees, whereas the total transfer-to-hospital rate (TTHR), when factoring in non-ambulance transport, was 0.25/1,000. In contrast to existing literature on transfers from music festivals, the most common reason for transfer off-site was for musculo-skeletal (MSK) injuries (53.8%) that required imaging. The presence of on-site HLC teams impacted the case mix of patients transferred to hospital, and may reduce the number of transfers for intoxication. Confounding preconceptions, patients in the present study were transferred largely for injuries that required specialized imaging and testing that could not be performed in an out-of-hospital setting. These results suggest that a better understanding of the specific effects on-site HLC teams have on avoiding off-site transfers will aid in improving planning for music festivals. The findings also identify areas for further improvement in on-site care, such as integrated on-site radiology, which could potentially further reduce the impact of music festivals on local health services. The role of non-emergency transport vehicles (NETVs) deserves further attention.TurrisSA, CallaghanCW, RabbH, MunnMB, LundA. On the way out: an analysis of patient transfers from four large-scale North American music festivals over two yearsPrehosp Disaster Med. 2019;34(1):72-81.

Exertional heat illness incidence and on-site medical team preparedness in warm weather.

To investigate the influence of estimated wet bulb globe temperature (WBGT) and the International Institute of Race Medicine (IIRM) activity modification guidelines on the incidence of exertional heat stroke (EHS) and heat exhaustion (HEx) and the ability of an on-site medical team to treat those afflicted. Medical records of EHS and HEx patients over a 17-year period from the New Balance Falmouth Road Race were examined. Climatologic data from nearby weather stations were obtained to calculate WBGT with the Australian Bureau of Meteorology (WBGTA) and Liljegren (WBGTL) models. Incidence rate (IR) of EHS, HEx, and combined total of EHS and HEx (COM) were calculated, and linear regression analyses were performed to assess the relationship between IR and WBGTA or WBGTL. One-way ANOVA was performed to compare differences in EHS, HEx, and COM incidence to four alert levels in the IIRM guidelines. Incidence of EHS, HEx, and COM was 2.12, 0.98, and 3.10 cases per 1000 finishers. WBGTA explained 48, 4, and 46% of the variance in EHS, HEx, and COM IR; WBGTL explained 63, 13, and 69% of the variance in EHS, HEx, and COM IR. Main effect of WBGTA and WBGTL on the alert levels were observed in EHS and COM IR (p < 0.05). The cumulative number of EHS patients treated did not exceed the number of cold water immersion tubs available to treat them. EHS IR increased as WBGT and IIRM alert level increased, indicating the need for appropriate risk mitigation strategies and on-site medical treatment.

The Event Chain of Survival in the Context of Music Festivals: A Framework for Improving Outcomes at Major Planned Events.

Despite the best efforts of event producers and on-site medical teams, there are sometimes serious illnesses, life-threatening injuries, and fatalities related to music festival attendance. Producers, clinicians, and researchers are actively seeking ways to reduce the mortality and morbidity associated with these events. After analyzing the available literature on music festival health and safety, several major themes emerged. Principally, stakeholder groups planning in isolation from one another (ie, in silos) create fragmentation, gaps, and overlap in plans for major planned events (MPEs). The authors hypothesized that one approach to minimizing this fragmentation may be to create a framework to "connect the dots," or join together the many silos of professionals responsible for safety, security, health, and emergency planning at MPEs. Adapted from the well-established literature regarding the management of cardiac arrests, both in and out of hospital, the "chain of survival" concept is applied to the disparate groups providing services that support event safety in the context of music festivals. The authors propose this framework for describing, understanding, coordinating and planning around the integration of safety, security, health, and emergency service for events. The adapted Event Chain of Survival contains six interdependent links, including: (1) event producers; (2) police and security; (3) festival health; (4) on-site medical services; (5) ambulance services; and (6) off-site medical services. The authors argue that adapting and applying this framework in the context of MPEs in general, and music festivals specifically, has the potential to break down the current disconnected approach to event safety, security, health, and emergency planning. It offers a means of shifting the focus from a purely reactive stance to a more proactive, collaborative, and integrated approach. Improving health outcomes for music festival attendees, reducing gaps in planning, promoting consistency, and improving efficiency by reducing duplication of services will ultimately require coordination and collaboration from the beginning of event production to post-event reporting. Lund A , Turris SA . The Event Chain of Survival in the context of music festivals: a framework for improving outcomes at major planned events. Prehosp Disaster Med. 2017;32(4):437-443.

Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)

BackgroundThe growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held...

LO020: Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)

Introduction: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on first responders, Emergency Medical Services (EMS) and local Emergency Departments. Literature concerning these events is minimal and mostly consists of media reports. Recognizing the lack of epidemiologic data, we sought to accurately determine the patterns and frequency of injuries and illnesses that occur at OCRs, the treatments required, and what proportion require further medical care or transfer to hospital. Methods: Data were extracted from medical charts completed for all patients presenting to the on-site medical team at OCR events across Canada from May to August, 2015. Frequency and patterns of injuries and illnesses were determined as well as treatments and disposition. There were 45 285 OCR participants in 8 events. There were 572 total patient contacts and 557 patients were included in the study. 15 patients were excluded because they were not race participants. Results: Less than 2% of participants at any event required on-site medical care. 11 patients (1.97%) required transfer to hospital by EMS. The majority of injuries were musculoskeletal in nature (74.71%). 495 patients (88.87%) returned to the event with no need for further medical care. The majority of treatments could be provided with first aid training and basic medical equipment. Conclusion: Injury and illness rates at this series of OCRs was similar to other mass gathering events. Injuries were mostly musculoskeletal in nature and required minor treatment. Having a medical team on site likely reduced local hospital and EMS volume from these events. This study raises the question of whether having a physician on site at OCRs could significantly reduce the number of patients advised to seek further medical care or the number of ambulance transfers. Prospective research is needed in order to develop plans for more appropriate resources, safety protocols, and medical staffing, thereby improving patient care and reducing the burden on local EMS and rural hospitals.

Planning and implementation of medical support for a cross-country obstacle race

Middle distance arduous outdoor events have risen in popularity over the last four years. This rise is accompanied by an increase in the number of injuries and anecdotally a rise in emergency department attendances. Event organisers are employing on-site medical teams to manage injured runners where possible and refer onwards appropriately when required. One such event is the WOLF RUN: a 10 km mud race with obstacles that provides runners of all abilities with a challenge. Events such as this require careful planning to reduce the risk of injury; however, should injury occur, this planning should lead to prompt assessment, treatment, and if necessary, evacuation. This article describes the event the medical planning that takes place prior each run, difficulties encountered and lessons learnt. We outline the requirements of a doctor taking on such an event, the medical resources and personnel required to safely staff it and the types of injury/illness that have been treated to date.

Disaster resilience in tertiary hospitals: a cross-sectional survey in Shandong Province, China

BackgroundHospital disaster resilience can be defined as a hospital’s ability to resist, absorb, and respond to the shock of disasters while maintaining critical functions, and then to recover to its original state or adapt to a new one. This study aims to explore the status of resilience among tertiary hospitals in Shandong Province, China.MethodsA stratified random sample (n = 50) was derived from tertiary A, tertiary B, and tertiary C hospitals in Shandong Province, and was surveyed by questionnaire. Data on hospital characteristics and 8 key domains of hospital resilience were collected and analysed. Variables were binary, and analysed using descriptive statistics such as frequencies.ResultsA response rate of 82% (n = 41) was attained. Factor analysis identified four key factors from eight domains which appear to reflect the overall level of disaster resilience. These were hospital safety, disaster management mechanisms, disaster resources and disaster medical care capability. The survey demonstrated that in regard to hospital safety, 93% had syndromic surveillance systems for infectious diseases and 68% had evaluated their safety standards. In regard to disaster management mechanisms, all had general plans, while only 20% had specific plans for individual hazards. 49% had a public communication protocol and 43.9% attended the local coordination meetings. In regard to disaster resources, 75.6% and 87.5% stockpiled emergency drugs and materials respectively, while less than a third (30%) had a signed Memorandum of Understanding with other hospitals to share these resources. Finally in regard to medical care, 66% could dispatch an on-site medical rescue team, but only 5% had a ‘portable hospital’ function and 36.6% and 12% of the hospitals could surge their beds and staff capacity respectively. The average beds surge capacity within 1 day was 13%.ConclusionsThis study validated the broad utility of a framework for understanding and measuring the level of hospital resilience. The survey demonstrated considerable variability in disaster resilience arrangements of tertiary hospitals in Shandong province, and the difference between tertiary A hospitals and tertiary B hospitals was also identified in essential areas.

An organized medical response for the Vancouver International Marathon (2006-2011): when the rubber hits the road.

We described an organized, on-site medical response for a large-scale urban marathon event and documented illness/injury rates as well as ambulance transfer rates at the Vancouver International Marathon (VIM). Case-series report of medical encounters was documented prospectively over a 6-yr period at the VIM. The planning and organization of the on-site medical response is the main focus of this report. A total of 67,402 runners participated in the VIM from 2006 to 2011. Over the 6-yr period, 2,986 patient encounters were documented. The patient presentation rate for the series was 45/1,000, the ambulance transfer rate was 0.09-0.58/1,000, and the medical transfer rate was 0.37-1.09/1,000. A coordinated on-site medical team covering the entire event site and race route was deployed to reduce the severity of illness and injury at a long-distance running event.

Extreme sports: Extreme physiology. Exercise‐induced pulmonary oedema

We report five patients who presented to an on-site medical team with concurrent haemoptysis and shortness of breath at a recent triathlon event. After initial management in the field, three of the five patients were transported to hospital via ambulance for further management, resulting in patients with haemoptysis and dyspnoea being 17 times more likely to require hospital transport. It is important to consider the differential diagnoses for this presentation, particularly exercise-induced pulmonary oedema.

Differences in Medical Care Usage between Two Mass-Gathering Sporting Events

Event planning for mass gatherings involves the utilization of methods that prospectively can predict medical resource use. However, there is growing recognition that historical data for a specific event can help to accurately forecast medical requirements. This study was designed to investigate the differences in medical usage rates between two popular mass-gathering sports events in the UK: rugby matches and horse races. A retrospective study of all attendee consultations with the on-site medical teams at the Leicester Tigers Rugby Football Club and the Leicester Racecourse from September 2008 through August 2009 was undertaken. Patient demographics, medical usage rates, level of care, as well as professional input and the effects of alcohol use were recorded. Medical usage rates were higher at the Leicester Racecourse (P < .01), although the demographics of the patients were similar and included 24% children and 16% staff. There was no difference in level of care required between the two venues with the majority of cases being minor, although a higher proportion of casualties at the Leicester Tigers event were seen by a health care professional compared with the Leicester Racecourse (P < .001). Alcohol was a contributing factor in only 5% of consultations. These two major sporting venues had similar attendance requirements for medical treatment that are comparable to other mass-gathering sports events. High levels of staff and pediatric presentations may have an impact on human resource planning for events on a larger scale, and the separation of treatment areas may help to minimize the number of unnecessary or opportunistic reviews by the on-site health care professionals.

Injury and Illness in Mountain Bicycle Stage Racing: Experience from the Trans-Sylvania Mountain Bike Epic Race

The popularity of mountain bicycle (MTB) riding has increased significantly since its inception in the 1970s, as have injuries from MTB riding. As MTB stage racing is a relatively new segment of MTB racing, the purpose of this study was to evaluate the injury and illness patterns associated with MTB stage racing to assist future medical providers in covering events. The Trans-Sylvania Mountain Bike Epic Race consisted of 7 stages. An onsite medical team of physicians, nurses, and paramedics provided medical coverage. The providers logged each medical encounter on a medical form. The log included the location where the treatment was provided (on course, at the finish or after the race), a description of the injury/illness, treatment that was rendered, the supplies needed for treatment, and the disposition of the patient (continue, withdraw but continue the next day, withdraw, or transfer to the hospital). A total of 52 athletes competed in the inaugural edition of the race. There were 30 separate medical encounters, with a total of 34 injuries/illnesses. Of these, 22 (65%) were classified as injury, and 12 (35%) were classified as illness. Four athletes withdrew from the race, 1 from injury and 3 from illness. Skin and soft tissue injuries/illnesses were the most prevalent. Injury and illness patterns of MTB stage racing are similar to those of other wilderness sporting events and prior data on MTB-related injuries. Minor skin, soft tissue, and orthopedic injuries are the most common. Illness accounts for the majority of withdrawals.

Hospital-Based Event Medical Support for the Baltimore Marathon, 2002−2005

Objectives. We present a four-year, cross-sectional epidemiologic description of injuries andillnesses among Baltimore Marathon participants andthe evaluation, treatment, anddisposition of those conditions by an on-site event medical team led by physicians andstaff from an urban, academic emergency department. Methods.We analyzed data from injuries encountered during the marathon. Subjects presenting to a medical aid station along the course route or at the finish line were defined as “injured or ill” andwere prospectively divided into two groups: 1) a brief-encounter group and2) an extended-encounter group. Data collected included gender, presenting complaint(s), assessment, treatment(s), anddisposition. Results.Three percent (N = 1,144) of approximately 33,700 total participants over four years presented to medical aid stations during the Baltimore Marathon between 2002 and2005. Most participants (66%) did not require a full clinical evaluation. Common complaints encountered were dehydration (32%), musculoskeletal injuries (25%), andcutaneous wounds (20%). Transport to the hospital was required for 4% of all injured participants, and61% returned to the race. Conclusions.Most injuries/illnesses encountered at the Baltimore Marathon in 2002–2005 were minor, although some were serious enough to require transport to a hospital. The year with the highest average race-day temperature had the highest observed injury rates andthe highest number of hospital transports. These results help to improve understanding of the types, severity, anddistribution of injuries commonly sustained by marathon participants andmay guide decisions regarding the appropriate distribution of emergency medical resources at such events.