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Extreme event medicine: considerations for the organisation of out-of-hospital care during obstacle, adventure and endurance competitions
  1. Linda Laskowski-Jones1,
  2. Michael J Caudell2,
  3. Seth C Hawkins3,
  4. Lawrence J Jones4,
  5. Chelsea A Dymond5,
  6. Tracy Cushing6,
  7. Sanjey Gupta7,
  8. David S Young8,
  9. Jennifer M Starling9,
  10. Richard Bounds1
  1. 1 Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware, USA
  2. 2 Augusta University Medical College of Georgia, Center of Operational Medicine, Augusta, Georgia, USA
  3. 3 Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  4. 4 Appalachian Center for Wilderness Medicine, Morganton, North Carolina, USA
  5. 5 University of Queensland Ochsner Clinical Foundation New Orleans, Los Angeles, California, USA
  6. 6 University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  7. 7 Long Island Jewish Medical Center, Emergency Medicine, New Hyde Park, New York, USA
  8. 8 Rush University Medical Center, Chicago, Illinois, USA
  9. 9 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  1. Correspondence to Dr Richard Bounds, Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Emergency Medicine Residency, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718, USA; richbounds{at}


Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

  • Prehospital Care
  • Major Incident / Planning
  • Trauma
  • Epidemiology
  • Remote And Rural Medicine
  • Environmental Medicine
  • Wilderness Medicine
  • Mass Gathering Medicine

Statistics from


Obstacle, adventure and endurance competitions in wilderness and remote settings encompass a multimillion dollar international industry that is exponentially gaining in popularity among the general public.1 2 Adventure racing includes activities such as trail running, mountain biking, canoeing/kayaking, mountaineering, climbing, cross-country skiing and orienteering.3 4 In obstacle course competitions, competitors navigate multiple challenges such as mud pits, fire and smoke, barbed wire, heights, immersion in icy water and even electrical shocks. Ultra-endurance competitions include foot races, mountain biking or cross-country skiing, and common distances include 50–100 mile races, as well as stage races (multiday events lasting 3–7 days).

Athletes are competing at their physical limits, and remote locations pose additional risks. Environmental hazards include wildlife, extreme weather, water and insect-borne infections, and challenging terrain. According to Young et al, ‘The problem is that people sign up and participate without always realising that serious injury is possible and that a handful of individuals have died in these events.’2 Although event organisers typically require participants to sign a waiver that emphasises the risks of injury, illness, disability and death, to indemnify the sponsoring agency from liability, there remains an underlying moral and ethical imperative to provide a reasonable level of medical care.1 Despite waivers, event organisers still have a duty to provide ‘sufficient first aid and emergency care’ and ‘trained and qualified staff’ to defend against claims of negligence.2

Compounding the risks inherent in this industry is the lack of a governing body that can promulgate uniform safety standards.2 Medical personnel, despite their education, skill and scope of practice, may be limited by resource availability and event management policies. If onsite resources are insufficient to manage the medical needs of a large event, local emergency medical services (EMS) agencies and hospitals may be overwhelmed.5

Our diverse author group, from various regions within the USA, has expertise in wilderness medicine and operational medicine as it pertains to outdoor competition and holds a variety of related professional affiliations, including the National Ski Patrol, the Wilderness Medical Society and the Appalachian Centre for Wilderness Medicine. We advocate for thoughtful planning and coordination of medical care delivery to mitigate risks in remote obstacle, adventure and endurance events. Furthermore, we propose a guiding framework supported by a review of the literature to bridge the fields of wilderness medicine and sports medicine in organising medical care at such events. The event size, location and nature of exposure should influence decisions related to qualifications of medical personnel, staffing guidelines, scope of services, equipment needs and integration with local EMS agencies.4 6 7

Defining wilderness event medicine

The concept of wilderness event medicine (WEM) is broadly defined as medical support for competitive sporting events outside the usual scope of local EMS.8 Burdick et al defined WEM as a healthcare response at any event with more than 200 persons located more than 1 hour from hospital treatment.9 While this definition focuses on physical distance from definitive care, it does not account for prolonged extrication time and specialised skills required for evacuation that may exceed local EMS resources. Hawkins et al note that wilderness EMS (WEMS) concepts may apply in situations involving a person injured at a ski resort or an urban nature preserve near a roadside when there is a need for specialised skills to extricate, manage or get supplies to the individual without the availability of an ambulance: ‘It is important to understand that WEMS is substantially more complex than the application of traditional medical training in a wilderness environment, and the indiscriminate application of traditional care and standards often proves to be dangerous to patients and/or providers in a wilderness setting.’10 In the context of this paper, we use the term WEM to represent any sporting event in a challenging environment that exceeds the capacity of local EMS systems either in transport time to definitive care or skills and equipment required for expedient extrication.


The authors used both MEDLINE and PubMed databases, cross-referencing the key terms wilderness medicine and event, with variations of the terms organisation, preparation and planning, to identify articles published in English from peer-reviewed journals from 1995 to 2016. Several textbooks, guidelines and position statements from national organisations (ie, National Association of Emergency Medical Providers, American College of Emergency Physicians, Wilderness Medical Society and American Medical Society for Sports Medicine) were used, in addition to the identified articles and their references, for the preparation of this paper. Through conference calls and online discussions, the authors evaluated the scope and quality of the references. When applicable, articles from the lay press and websites that promote or organise wilderness endurance events and obstacle races were reviewed to gain a better appreciation for the scope of the issues and the need for greater organisation of event medical care. The authors achieved consensus on the resources and considerations provided in this paper.

Medical problems commonly encountered in WEM

Data regarding the most common medical conditions encountered in remote endurance events are limited, but extrapolation from more common urban events may be applicable to the wilderness setting, especially when the disciplines are similar.11–17 In urban running events, musculoskeletal injuries, dehydration and dermal injuries are most commonly encountered.18 19 Urban triathlon and cycling events demonstrate a similar incidence of skin and musculoskeletal conditions, with orthopaedic injuries and dehydration representing the more common reasons for participant withdrawals and ambulance transfers.20–23

Injury and illness patterns at remote endurance events vary tremendously based on the specific characteristics of the course and participants, with the most common conditions including blisters (32%–46% incidence),13–16 24–26 nausea and vomiting (24%),27 respiratory illness (4%–57%),24 26 fractures/dislocations (2%–38%)16 25 28 and dehydration or heat illness (4%).15 Although serious injuries and fatalities do occur in wilderness competitions, most medical conditions are non-life threatening. Fatalities are uncommon. In adventure racing, for example, the estimated mortality rate is 1/100 000 racer-days.9 Conditions specific to particular geographical locations, such as high altitude or temperature extremes, may influence illness or injury patterns and rates.9 19 29 30 Table 1 lists conditions encountered in WEM.

Table 1

Medical conditions potentially encountered in wilderness sporting events5 9–11 21 31–34 36 38 53 56

There are also unique injuries and illnesses encountered at obstacle races. While there are some reports in the lay press of severe injuries and fatalities due to heatstroke, spinal cord injury and drowning,31–34 there is a paucity of peer-reviewed literature regarding these types of events. One obstacle race case series reported a high incidence of skin, soft tissue and musculoskeletal injuries, as well as unusual conditions such as myocarditis from electrical shock.5 The same case series reported participants with altered mental status, stroke, cardiac demand ischaemia, near syncope and rhabdomyolysis.5 Relatively rare conditions have been reported after both obstacle races and remote events including Campylobacter sp infection,35 rickettsia,9 36 myiasis9 37 and leptospirosis.9 38–41

Qualifications, scope of practice and staffing for medical coverage

The composition and number of WEM team members are influenced by the event size, number of participants, number of aid stations and anticipated risks from both the environment and the competition itself. It is recommended that medical directors supporting wilderness competitions have an understanding of applied technologies used in the specific event setting (eg, communication devices, navigation systems and point-of-care testing equipment) and have the ability to organise and interface effectively with local medical resources and support systems.6 42 The medical director's efforts are typically augmented by a group of support staff, such as nurses, physician assistants, emergency medical technicians (EMTs) and paramedics, as well as event personnel with environment-specific skills and technical rescue qualifications as needed.6 Table 2 lists examples of the qualifications and training programmes that might be appropriate depending on specific event characteristics.

Table 2

Examples of potential qualifications based on specific event characteristics

In general, the literature supports that members of the medical team in remote locations:

1. Hold an appropriate nationally recognised medical licence or certification (eg, MD/DO, RN, EMT) and work within the jurisdiction's regulatory authority related to scope of practice.6 42 43

2. Work in cooperation with, or as part of, the local EMS and healthcare system.6 43

3. Be knowledgeable of relevant consensus documents, standards and guidelines from wilderness medicine, sports medicine and prehospital organisations that are applicable to the delivery of event medical care.6

4. Involve a physician medical director to establish quality management processes, direct personnel with dependent licences (eg, nurses, EMTs and paramedics) and assure adherence to evidence-based standards of care.6 43

Medical support planning: logistical considerations

The development of a well-conceived WEM support plan is contingent on event size, experience of competitors, potential health risks, available resources and environmental factors.4 6 44 This plan is best shared with the event organiser and endorsed to achieve a coordinated, consensus-driven approach. Recommended plan logistics include equipment needs, communications, medical team orientation/coordination, removal of injured participants, documentation of medical encounters, transportation issues, integration with local EMS resources and risk mitigation strategies.2

Recommendations for minimum equipment

Medical equipment needs are based on the event type, qualifications of onsite personnel, natural hazards and climate.8 45 Reviewing past cases or event statistics from previous competitions can help to predict future equipment needs.5 6 Box 1 offers considerations for basic and advanced medical supplies and equipment.

Box 1

Considerations for basic and advanced medical supplies and equipment

Basic equipment:

  • Gloves,

  • Bag-valve-mask,

  • Oral/nasal airways of various sizes,

  • Automatic external defibrillator,

  • Blood pressure cuff,

  • Stethoscope,

  • Hypo/hyperthermia thermometer,

  • Splinting supplies (eg, SAM splints; traction splints),

  • Triangular bandages/cravats,

  • Zip-ties trauma sheers/scissors,

  • Ice and/or chemical cold packs.

Wound care:

  • Gloves,

  • Wound irrigation supplies,

  • Gauze,

  • Adhesive bandage,

  • Medical tape,

  • Elastic bandage,

  • Kinesiology tape,

  • Blister care supplies: antiseptic, needle, moleskin, non-adherent dressing or commercial film/gel-type blisterdressing,

  • Tissue adhesive.

Comfort/personal hygiene:

  • Tampons/pads,

  • Vasoline,

  • Sunblock,

  • Mylar blankets.

Advanced equipment:

  • Intravenous fluids,

  • Intravenous start kits, intravenous tubing, alcohol pads,

  • Hypertonic saline,

  • O2 saturation monitor,

  • Blood glucose monitor,

  • Point-of-care blood analyser,

  • Pregnancy test,

  • Portable ultrasound,

  • Cardiac monitor/defibrillator,

  • Intubation equipment,

  • Oxygen cylinders,

  • Non-rebreather masks,

  • Syringes/needles,

  • Laceration repair supplies,

  • #11 blade scalpel.s


  • Epinephrine/adrenaline (intramuscular and intravenous),

  • Albuterol metered-dose inhaler,

  • Diphenhydramine intramuscular/intravenous, oral, or chlorphenamine,

  • Cimetidine or ranitidine,

  • Acetaminophen/paracetamol,

  • Aspirin,

  • Ondansetron,

  • Omeprazole/Losec,

  • Antacid tablets,

  • Oxycodone,

  • Nitroglycerin,

  • Prednisone,

  • Ciprofloxacin.


The health and safety of participants for anything but the shortest races rely heavily on consumption of fluids, electrolytes and calories.46 Most competitions supply some food and water. In extreme events where competitors are required to be completely self-sufficient or face being disqualified if they seek support, we advise that checkpoints maintain supplies to offer basic sustenance for participants with medical necessity.

Medical aid stations

Aid stations are typically placed in safe, high-visibility locations with easy access to extraction points. The structure should offer protection from the elements. Noting course hazards and reviewing medical needs from prior years can drive placement decisions.6 Adventure races vary widely; medical tents are often placed in a central location. Commercial obstacle races generally have a medical tent at the start or finish. The major 100-mile trail races have on-course checkpoints, usually with associated medical aid stations.47 In urban events, medical presentations typically occur near the finish.18 21 48 In contrast, injury rates tend to be higher throughout the course in wilderness settings.9 27 One 5-day ultra-marathon reported that the most medical needs occurred on the longest stage as well as the last day of the race.28 Overall, the location and number of aid stations and medical tents are best determined by the environmental challenges, event and participant characteristics, and anticipated risks in particular areas of the course.6


While effective communication systems are vital to any medical support operation, there is a paucity of literature about communication systems in WEM. For small events, communications may be limited. For larger scale events, the authors’ experience indicates that multiple communication methods may be employed: landline, cellular and satellite phones; fixed and mobile radios, with multiple frequencies to connect with separate operational sectors; and a designated incident command post. In remote areas, communications may be extremely limited due to radio or network ‘dead zones’, and coverage should be evaluated in advance to identify problem areas. Ideally, medical operations are conducted through a dedicated frequency or channel. A contact list that includes phone numbers, radio channels and radio identification of race officials, medical team members, EMS contacts and other important resources is helpful.

Medical support team orientation

In our collective experience, a structured orientation for the WEM team helps to ensure coordinated operations. Optimally, orientation occurs before the event. However, if scheduling and logistical challenges preclude an advanced briefing, alternatives include day-of briefings, distribution of written guidelines and orientation via electronic media. Briefings held at intervals during longer events keep team members informed of operational issues, risk situations and subsequent plan modifications. Box 2 lists topics for consideration.

Box 2

Suggested topics for event medical personnel orientation

  • Overview of the medical support plan and logistics

  • External resource availability and methods of contact

  • Equipment checklist with locations

  • Operational policies and procedures

  • Communications protocols and radio operation

  • Documentation requirements

  • Staffing guidelines and expectations

  • Medical and event chain of command

  • Potential health risks to participants, spectators and staff

  • Anticipated illness and injury patterns

  • Treatment protocols and evacuation guidelines

  • Special participant populations, if known

  • Privacy policies

Removing medically compromised participants

While most competitions do allow participants to receive medical intervention, some assign penalties or disqualify participants for accepting medical support. In any event, participants who require evacuation off of the course will be disqualified. Ill or injured participants, therefore, may be reluctant to seek care or discontinue competition when recommended. Event protocols that specifically authorise the medical team to disqualify a participant for their safety are recommended.4 6 49 It is suggested that this authority be made explicit to athletes, support staff and EMS personnel.6

Documentation of medical encounters

A medical encounter record is typically generated for participants who require significant medical assistance. This may involve a basic contact log with date/time, participant name, age, bib number, chief complaint, findings, care rendered and name(s) of the medical provider(s). More comprehensive documentation may include vital signs, examination findings, interventions, narrative notes, follow-up recommendations and, if transported, the EMS unit and destination medical facility. If resources permit, a copy of the treatment record can be provided to EMS.

We suggest that athlete bib numbers be used to quickly link the encounter to the participant's registration and emergency contact information. Organisers can also request that participants list pertinent medical conditions, allergies and medications as part of race registration. Recording this information electronically or simply writing it on the back of the race bib offers ready access to vital information in emergencies.

Transportation issues

In our experience, accessing, stabilising and evacuating injured or ill participants can pose significant transportation challenges in rugged or remote settings. Large crowds, narrow trails, challenging terrain and courses extending over large areas can complicate onsite rescue. Foot teams, bicycles and all-terrain vehicles may be used to reach injured participants. Prior review of the course layout to identify access points for ambulances and helicopters, especially in more inaccessible sections, is important to decrease transport time to definitive care. We recommend that medical team members have an accurate course map with aid stations, vehicle and EMS access points, and obstacles clearly marked.

Integration plan with local EMS and emergency resources

Given the potential for increased healthcare demands, we suggest coordination with local EMS agencies and medical facilities to determine their capacity to support a potential influx of patients.5 When the local jurisdiction cannot provide sufficient primary coverage, event managers may contract with external resources. In these situations, it is important to consider the following questions:

  1. Are the contracted assets licensed and permitted to fully operate in the jurisdiction?

  2. Are their prehospital protocols and communications aligned with the local agency and medical facilities?

  3. Is the local agency capable of providing backup assistance?

  4. Can the medical facilities handle the potential influx of arrivals?

Since technical rescues often require well-coordinated efforts, the need for assistance from local search and rescue organisations, a medical helicopter and law enforcement agencies should be anticipated.25 Pre-established indications for helicopter evacuation and potential landing zones approved by the flight crew to minimise evacuation delays are recommended for more remote, high-risk events.50 For seamless integration with EMS resources, we advise dissemination of the medical team's protocols and determination of whether an event physician can provide medical control to an outside EMS unit.

Medicolegal considerations

Events of all sizes may benefit from having a physician medical director involved with medical care delivery.42 The medical director roles may include participation in event planning, selecting appropriate medical personnel and ensuring adequate facilities and equipment for treating the anticipated scope of encounters.6 This model potentially optimises medical care and may help limit liability.51 Physicians and other licensed healthcare personnel who volunteer in a locality in which they do not hold a licence may be considered providing unlicensed care; applicable laws should be reviewed in advance of the event.

In light of a recent reduction in physician volunteerism for events due to liability concerns, multiple large marathons and triathlons have started offering their teams medical malpractice coverage.52 Providers may also consider obtaining a rider on their own professional liability insurance or a separate liability policy to cover an event, but these options could be unavailable or cost prohibitive.51 Physicians may have the opportunity to join specific organisations that contract with events and offer malpractice insurance for those working under their umbrella.

Good Samaritan laws in the USA, for example, are not intended to provide protection to medical personnel at athletic events, as the laws only apply to emergency care. WEM care may involve non-emergent treatments (eg, dispensing analgesics, managing sprains, wound care).51 Furthermore, a medical volunteer may not have Good Samaritan immunity because of the duty implicit in agreeing to serve in this role.53 Stewart et al discusses the Good Samaritan Laws of all 50 states.54 Event medical personnel can limit liability risk by understanding applicable licensing laws and liability concerns in the location where they are volunteering.51 54

Postevent quality assurance and improvement

Timely and accurate feedback are key components of postevent quality assurance and improvement. Communication between event organisers, volunteer personnel, athletes and medical staff best occurs soon after the event. Near-misses, defined as situations that might have resulted in medical treatment but did not, can be identified to better prepare for potential incidents at future events.9 55 Consideration should be given to course hazards, equipment or staff shortages and potential rescue scenarios for future planning.6


We have aimed to offer considerations supported by relevant literature and our collective experience for the provision of care at remote obstacle, adventure and endurance competitions. While this discussion covers a broad scope and addresses many important issues, each event is unique. The organisation of medical care is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements and the availability of both local and outside resources.


View Abstract


  • Contributors The author group includes leaders of the Appalachian Center for Wilderness Medicine and the Wilderness Medical Society, and all those listed have contributed substantially. LL-J spearheaded this effort by developing the concept, organising this group and coordinating in-person meetings, conference calls and electronic communications. Individual sections were authored as follows: Abstract, Methods and Conclusion: RB; Introduction, Defining WEM: TC and CAD; Medical problems: MJC; Certification, Scope of practice: SCH and JMS. Logistics: equipment, fuel/fluids, medical tents: DSY; communication, orientation, documentation, transportation, integration with EMS: LL-J and LJJ; removing unsafe participants: RB. Medicolegal considerations: SG. Postevent QA: LL-J. LL-J and RB brought the various sections together into a cohesive multidisciplinary work that represents the group’s collective recommendations.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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