Emergicare Medical Training

An affiliated Educational Center of the

“You Look Sick”:

Rolling patient assessment for EMS bike teams at foot races.

By Hans Erdman, WEMT

National Mountain Bike Patrol Instructor/Trainer

Isanti , MN

Click here to read the related article on Scene Safety for medical bike teams. (Off-site)

Trip, slip, stagger or stumble? If you know what you are looking for, the slightest misstep can tell you volumes about how a runner is feeling. So it was at the unseasonably warm Medtronic Twin Cities Marathon last October, when the young woman who is running next to me in the photo above, staggered at the 14-mile point of the race. I rolled up next to her and asked how she was doing. She insisted that she was fine, just a bit tired, and could continue on. My partner and I monitored her for a while, until we were flagged down by a first aid station to assist in the assessment of yet another heat illness patient. After we turned that patient over to the paramedics, we continued on the course only to find the object of our previous concern flat on her back with her feet elevated at the next aid station a mile later. The doctors at that station felt her problems were much more significant and serious than just being tired.

Minnesota ’s volunteer National Mountain Bike Patrol (NMBP) units have been assisting at special events since 1996, when the newly-created North-Central Mountain Bike Patrol helped save the life of an asthmatic woman who collapsed at the very first mountain bike event the patrol worked. In 2003, the North-Central patrol split into two separate units, the MORC (Minnesota Off-Road Cyclists) Mountain Bike Patrol serving primarily the central and southern Twin Cities area and the Backcountry Trail Patrol which covers Hillside Park in the far north-metro city of Elk River , and trails in Minnesota ’s Chippewa and Wisconsin ’s Chequamegon National Forests . The patrols have been part of the Twin Cities Marathon medical team since 1998, riding the 26.2-mile course with AEDs (Automatic External Defibrillators) and basic first aid equipment. We also work three triathlons, a dualathon and many mountain bike races and charity/social bike rides each biking season. Over the years we have assisted with everything from blisters and sunburn to bee-sting anaphylaxis and a cardiac arrest, and we have developed a “sixth-sense” when it comes to figuring out who is tired, who is exhausted, and who could potentially have even more serious problems.

Each year we deploy approximately 10 to 14 NMBP patrollers on the TCM course in teams of two, consisting of a First Responder, OEC*, or EMT level patrol member teamed up with a first aider (or better). Most of the teams enter the course from the five-mile point, every five minutes after the elite-class runners pass that location, with one team doing sweep from the starting line at the Hubert Humphrey Metrodome in downtown Minneapolis . The teams carefully ride along with the 10,000-plus runners, watching for medical problems, and assisting competitors when needed. The 2006 Twin Cities Marathon experienced much warmer than normal temperatures for early October in Minnesota . Although temperatures at the race start were around 50 degrees (F), they quickly rose to a high of 83 by noon. We were faced with a far larger number of heat-related illnesses than at a typical October marathon, when air temperatures would be in the 45 to 60 degree-range. There were two cardiac arrests, one of which was successfully resuscitated, and large numbers of heat cramping and heat exhaustion cases, including a number sent to local emergency rooms by ambulance. (Conditions for the TCM in 2007 were even worse, with temperatures near 90 degrees and extremely high humidity, on a Sunday when, only one week earlier, the National Weather Service had predicted the possibility of snow.)

When a patroller works their first marathon, it is sometimes difficult to prepare them for some of the things they will see on the course, even in normal temperatures. Different runners prepare for the race in different ways, and the amount of effort they put into training shows up in sometimes alarming ways. Oftentimes, in the last few miles of the course you will see a runner with salt crystals caked on the sides of their face, pale and diaphoretic, but they will wave off offers of assistance, because they are accustomed to running long distances. They have been hydrating adequately with sports beverages, so their electrolytes are good (hence the salt build-up on their face) and their pace is sound, so you just make a mental note and continue on. We also, on occasion see participants with bladder and bowel incontinence, and vomiting water (symptomatic of early stages of Hyponatremia), food, or bile. In the proper context, each of these problems may or may not indicate an emergent situation. The key to knowing what may be an emergency harkens back to the very first thing we learn as medical responders…good patient assessment system (PAS) techniques.

Obviously, (Hopefully?) the runner is up and running, so the ABCs are covered. But before that, as you ride up behind a runner, (Because almost all the time you will approach them from behind.) what is your first impression? What do their pace and their gait look like? You can tell a lot about a runner’s overall condition just by observing their movements. Are they lifting their feet with each step? Is the pace even? Are they moving forward at a steady pace, or is it varying, and by how much? If they are shuffling, is the leg movement steady or erratic? Often amateur runners, particularly those new to marathon races, will slow to a shuffling gait in the last five to ten miles of the event, but their progress will be steady and, other than looking tired, their overall appearance is okay. Are they limping, or is their gait uneven or irregular? Some runners may, for benign reasons, favor one leg over the other but their favoring or limp will be consistent, whereas somebody with a problem, whether it is blisters, cramping or musculo-skeletal, will instinctively attempt to run normally, resulting in a more erratic limping action. Riders should particularly be on the watch for stumbling or staggering. Stumbling is more indicative of exhaustion, but can also be caused by irregularities in the running surface, failing to lift the foot high enough for the sole or toe of the shoe to clear the ground or other mechanical reasons. Staggering, on the other hand, may indicate the onset of a more serious medical problem, as in the case at the start of this article. When a person staggers while running, their whole countenance changes, and this is pretty obvious from the rear. Their feet stumble, and it may be mistaken for just that, but along with the stumble, the runner seems to drop or shrink perceptively. Shoulder posture sags, the head may tilt forward almost to the chest and the arms lower or drop completely down. Usually, the runner recovers and presses on, but this is a person worth watching. If the staggering repeats, the runner may actually go down, resulting in traumatic injuries in addition to the systemic problems. Staggering may be a symptom of serious medical issues including hyponatremia, cardiogenic or hypovolemic shock, or heat-related illness.

How are they carrying their shoulders and arms? Arms down at the side may or may not be much of a concern, but if the arms are stationary while the rest of the body is in motion, or the fists are clenched, with the arms either up or down, it may be in response to pain, cramping or other physical discomfort. Arms flopping loosely at the side may be a sign of exhaustion, as may slumped shoulder position. Abnormally high shoulder position, with the neck tight and head drawn down may indicate muscle spasms in the back or shoulders. Normally, a runner will hold their arms bent 90 degrees at the elbow, with normal, natural movement from the shoulder as the runner strides.

Facial appearance and interviewing are the last two parts of assessing a runner while on the roll. If any of the previously mentioned indicators has given you a cause for concern, pull along side the person and look at them. Usually, these symptoms are evident from the midway point of the race, where the runners are pretty well spread out, so riding next to the runner is not an issue, but remember to keep a wary eye out for other racers, spectators, your partner, etc., while you are doing this. (This is one time your IPMBA slow speed riding drills come in really handy!) What is their facial appearance? Sweating freely? Pale or red-faced? Is there salt along the sides of the face or in the hair? Any bleeding evident from the nose or mouth? (Yes, that is a red flag!) You really only have a second or two to determine these things. Then simply ask a non-threatening question of the runner, such as “How’re you doing?” or “Are you okay, runner?” Try not to interrupt their pace, but listen to their response very carefully. Listen to the quality of their response, as well as what they say. Are they breathless beyond what should be normally expected. (Runners in good condition, even non-elite classes, often carry on conversations with their co-runners right up to the finish line.) Does their pace alter perceptively while they answer you? This may indicate all their effort is going into keeping going. Do they just nod, fail to answer, or acknowledge you? These are runners to be concerned about. Does the runner “look sick”? At least at our first responder-level in the operation of the Twin Cities Marathon, we cannot pull racers off the course except in a bona-fide emergency, but if the overall condition of a runner concerns you, get their bib number, and pass it on to the next couple aid stations, so they can be watching for the person. Often, your concerns are justified, and the runner will stop at an aid station because they don’t “feel right”. However, if you are ever confronted with a set of symptoms that indicate the runner should be a patient, don’t hesitate to either pull them over, or at least shadow them to the next aid station.

The Medtronic Twin Cities Marathon has an excellent reputation for providing the highest quality medical support to the 10,500 runners in the event. Under the direction of Dr. Bill Roberts, one of the most highly regarded marathon medical experts in the country, the event staff of doctors, nurses, physical therapists, paramedics, EMTs, Ski Patrol OEC* Techs, First Responders and first aiders has historically provided one of the safest marathon events in the world. The volunteers of the National Mountain Bike Patrol have been part of that response for nine years. Once again, on the first Sunday in October in 2008 the red jerseys of the NMBP will be seen working their way through the runners on the course of “the most beautiful urban marathon in America .”

*OEC-National Ski Patrol Outdoor Emergency Care training

This article was reviewed prior to publication, by:

Kevin Ronnenberg, MD – Medical Director, Chisago-Lake Country Triathlon

Peter Hanson, MD – Medical Director, City of Lakes Loppet Urban Ski Marathon

William Roberts, MD, FACSM – Medical Director, Medtronic Twin Cities Marathon

Click here to read the related article on Scene Safety for medical bike teams

Questions or problems regarding this web site should be directed to Click to send us e-mail 
Copyright © 2008 Emergicare Medical Training, Inc. All rights reserved.
Last modified: Monday October 13, 2008.