Race Medical Planning

Episode transcript

Panos  2:22  
Natasha, welcome to the podcast.

Natasha  2:24  
Thank you for having me.

Panos  2:25  
Well, thank you very much for coming on. I know you're a very very busy person. Are you travelling today? Are you at home?

Natasha  2:32  
Yeah, currently at home. I'll be at the clinic this afternoon, but I've got a bit of a relaxed morning and time to speak to you guys this morning. 

Panos  2:39  
Awesome. And what's home for you?

Natasha  2:41  
So I'm based in London just south of the river - when I'm actually at home. As you'll hear probably a little bit later on, I travel quite a lot. But yeah, been in London for a good 20-odd years now.

Panos  2:51  
How are things in London?

Natasha  2:54  
Bleak. It's probably not warm. It's not sunny, and we've got a national shortage of tomatoes. Yeah, it's going well in London.

Panos  3:04  
Is it just the tomatoes? I've been following the whole vegetable situation in London. I hear all kinds of, like, salad vegetables have been hit pretty hard.

Natasha  3:12  
Yeah, apparently, it's a Europe-wide issue. But certainly, social media leads us to believe it's not. It seems to be very much a UK issue at the moment.

Panos  3:21  
Yeah, I looked into it a little bit. What I came up with is that supermarkets are not willing to pay the price. I think that's the bottom line of it.

Natasha  3:28  
Yeah. And I think the problem is, in the UK, people will just go, "I won't buy salad." I mean, during lockdown, the first lot, we had real problems with loo roll. Now, we seem to have moved on to tomatoes as an issue. Yeah, the UK is stupid at times but we just roll with it.

Panos  3:44  
Plenty of root vegetables, well, if you want to fire up a stew or something. 

Natasha  3:47  
Yeah, apparently we've been told to eat turnips. Apparently, we have lots of turnips. I don't think anyone actually eats turnips though. So that's probably why there are plenty of them around.

Panos  3:56  
Yeah, I mean people used to-- when you're used to tomatoes and peppers and stuff, turnips salad sounds a little bit rough. 

Natasha  4:04  
Yeah. 

Panos  4:05  
Tell our listeners a little bit about yourself. There are so many things you do. Your day must have, like, extra hours or something to mind because you seem to be, like, the medical director in, like, a dozen events and organisations, and you're running your own event medical company on top of everything else. So tell us about everything that you do in the industry.

Natasha  4:25  
Kind of, in brief, my training is I'm a sports and exercise medicine consultant. So what that means is I'm a doctor that's then trained in sports medicine within the NHS. And from that point, we all tend to have kind of what we call a portfolio career, which means that we don't just work in one discipline. Granted, there are some doctors that will work in just football, for example, because that takes up their life whereas most of us will work in different sports, different environments. And so for me, that means that I work in the clinic, meaning I see normal people - not necessarily sporting - just people with back pain, hip pain, and knee pain. I say they don't have to be sporty or they can be. I'll see up to kind of elite athlete level. On top of that, I work for the Lawn Tennis Association. So two days a week, I am there and I look after the performance players. So all the names that you see playing at Wimbledon, US Open, Indian Wells that's coming up, I look after them. And then on top of that, I run a sports medicine company that does medical cover for relatively big events, either mass participation, kind of marathons, half marathons, triathlons, or more elite-specific, so international tournaments like the world indoor athletics, or the world gymnastics. And so yeah, I kind of work for lots of different organisations in different environments and it's fun. It's busy. It's long days, but I enjoy it.

Panos  5:54  
And the NHS, you mentioned there at the top of your answer is, of course, the much revered National Health Service that we all love in the UK. This is for our US listeners. We have plenty of those. So I just want to clarify. In terms of the races that you sort of oversee, can you give us a couple of names? I saw quite a lot of, like, heavy hitters on your LinkedIn profile.

Natasha  6:13  
Yeah, there's a fair mix and, obviously, over the years, it changes. I suppose the big one that people will have heard of is Manchester Marathon, which is kind of the second biggest marathon behind London. Then, we'll also work on things like London Winter Run, which will be a 10K. Triathlon-wise, we would like to blend in or London triathlon or the all the World Championships, which are normally in Leeds, but moving to Sunderland for this year. And then, kind of historically, we've done a slightly tenuous link to running. We worked Tough Mudder for five years. So planning the medical cover for obstacle course racing, which was essentially a 12-mile run plus challenges. It's probably the easiest way to describe it along the way.

Panos  6:58  
Yeah. And Tough Mudder actually was your gateway to this whole thing, right? It's how you got involved with races as a medical director and went on to do the kind of things you do.

Natasha  7:08  
Yeah, I mean, I kind of fell into this. I often get asked how I ended up doing this job and I'm still not entirely sure how it happened. I just remember being away with England hockey in Belgium and getting a phone call from the event director of Tough Mudder saying, "Oh, we'd like you to be a medical director." I mean, I'd never heard of the event. I didn't have a team. I didn't have any equipment. And for some bizarre reason, I said, "Yes." Obviously, with some background research into what I was then getting into, I suppose, I mean, it doesn't matter where in the world you are. The event industry is relatively small. And what tends to happen is you work for event, the event director leaves or someone else from the team leaves and goes to a different company. Then, they phoned you and asked if you can could in and do that, and it just kind of snowballed from that. And yeah, I loved working with Tough Mudder. It was hard work, medically very, very busy. Very interesting, though. You had to really think about the challenges of each different race, different environments, different how hilly it was, what the access was like, where they're allowed to dig obstacles, where they have to put high obstacles, and that's all restricted, in essence, by the landowners. So it kind of really made me think. It's not just a case of putting in a replica medical cover in every event you do. You really have to appreciate the environment that you're working in and it taught me loads so, so much, and I apply those principles to all the events. So I work out now. The Tough Mudder I used to do site visits and turn up with a spade so that I could dig up the ground and see if it was flipped or stoned in certain areas. Obviously, I don't have to do that if it's a road race in central London, but you still got to think about where can you stick medical posts? What does it look like? Can you access it? Where are people likely to collapse? So yeah, I learned an awful lot and it was a baptism of fire but it was a real learning experience.

Panos  9:01  
And they're not making your life any easier - those obstacle races - I think. Isn't it that they use, like, electrified nets or something? Like, very, very low voltage, I hope, but still electrified.

Natasha  9:13  
Yup. We used to electrocute people. In fact, they still do. Yeah. Again, it's working out which participants you can allow through those obstacles which you can't. So, if you know, for example, that they've got the ability to have seizures, if there's someone who's epileptic or has non-epileptic seizures, lots of strong messaging, "Do not go through this obstacle." Actually, let's say, it is low voltage, it stings, it burns, but it's not horrible. But the aim of those obstacles is to challenge you. So what is your fear? Is it height? Is it water? Is it being in a confined space? Is it being electrocuted?

Panos  9:49  
Is it all of the above?

Natasha  9:52  
If it is, you probably shouldn't be there. You'd never get very far. It challenges people and people loved it, and it was a great set of events to work on.

Panos  9:59  
Yeah, It's a nice event. I did one in Battersea actually. 

Natasha  10:02  
Oh, was that one of the 5K ones? 

Panos  10:04  
Yeah, it was ages ago, but it was a great experience actually. It was really nice. Like, combining, as you say, the whole endurance thing with the obstacles, and everything was great. And you yourself are quite a sporty person, right? You were telling me offline that you're going off on a tennis holiday and stuff.

Natasha  10:24  
Yeah. It's not my not-so-secret passion that I am absolutely tennis-obsessed. So working for the Lawn Tennis Association is kind of a dream job. I just love sports. I love everything about it. It's the area of medicine I've chosen to work in. Like, we get asked as a company to do festivals and concerts for medical coverage and we turned it down. It's not our bag. It's not what we're trained in. We pride ourselves in our knowledge of Sports Medicine, which is slightly different from event medicine. Event medicine is just kind of generic medical cover, whereas we want to take that step further and give our patients that little bit of higher level care and also all the anti-doping rules that you need to know about when it's an elite event. We as medics need to know about that. But yeah, I do probably then take it slightly beyond and then go off and play a lot of tennis when I can. I don't really know how I fit it in and there are definitely months where I don't fit it in when the event season is manic. But this time of year, I just got a little bit of breathing space before it really starts to kick in.

Panos  11:30  
That's awesome. Enjoy it. Well, let's have a look actually at that since you mentioned the whole, I guess, the distinction between generic event medicine, which is, like, showing up at a concert or something, and the kinds of things that we're looking at. And let's put aside the elite side of things for a sec, which has its own complications. Looking at mass participation, the kinds of things that the people listening in, the kinds of events that is the kind of bread and butter to put on, the marathons, the 10Ks or triathlons-- before we get into the planning and preparing and getting ready for all that stuff, as a race director, I was actually quite curious to get your take a little bit on the physiology of the average runner, or cyclist, or whatever going through this kind of thing, right? Because I think it might be surprising how much stress even a casual 5, 10K can put on a person, particularly when they're out there running for time or whatever. Can you sort of, like, briefly give us a little bit of a glimpse into all that - what's happening in the human body when someone is out there doing that stuff?

Natasha  12:40  
Yeah, I mean, I think the first thing to say is there's no average participant. Everyone is doing these events for a different reason, be it they might be entering a 5K now, but it's part of a stepping stone for them ultimately trying to do a marathon in a year's time or so. It's progression. Then you've got people that just want to do a 5K and they're doing it for the social elements of fitness, and they're not there for time. They're just there to enjoy the environment. And then, you've obviously got your charity runners as well who are doing it for something that means something to them. They're sometimes the hardest ones for us to work with because they're the ones that have got all that pressure of all the money that they've raised, and we're saying, "You need to stop. You can't run. We think you've got a stress fracture," for example. It means so much to them. And then you've got the ones who really aren't going for time, the ones who are standing at that start line, they're the ones who are absolutely at the front with their watches, ready, and they will push and push and push themselves. Medically, they are probably the ones that we see the sickest element of-- most people with musculoskeletal injuries, sore knees, sore backs, they've fallen over, they've tripped over something. It's the fast ones that are the ones that probably have the most extreme changes to their bodies when they're running. And I suppose the thing that we'll worry about is when they get too hot. When you exercise, your muscles generate heat and it's definitely more of a male thing than a female thing, and we think that's twofold. One, men generally have more muscle bulk, so therefore they generate more heat. But also, women tend to be a bit more sensible. 

Panos  14:20  
I can see that. 

Natasha  14:21  
And if they don't feel well, they tend to slow down a little bit. It does happen to women. But certainly, in the medical tent, I mean, if I was to analyse the data of those who come in collapsed because of being too hot, it's probably 90% male. It's a very male thing. And they can be incredibly sick. They can be everything from just not feeling quite right, that's fine, to having rectal temperatures of 42 degrees, unconscious fitting. If they're not treated quickly, they can die from this and that's something that you have to be absolutely prepared for. And I've seen it even in a 10K that, with an air temperature of four degrees, we still have people coming in hot, and it's that "going for time" element. And then there's the kind of surprise every-- well, not surprised because we anticipate it but the cardiac issues, the heart attacks that happen at the events. And people will say, "Well, why do they happen in events and not when they're training?" I think, when you're training, there's less pressure. It's not the day. You haven't got the anticipation, the nervousness of the day. And it's just that extra stress. We see it in the elite world. Like, for example, Fabrice Muamba the footballer that had a cardiac arrest. Oh, God, it was probably around 10 years ago now while playing a football match. He, as an elite athlete, has cardiac screening every single year, as a minimum, stressed out on a treadmill. Everyone's looking at their heart racing. Yet, he still went on to have a funny heart rhythm that led to a cardiac arrest on the pitch, and that's because you can't ever replicate the environment of the match, the race, in a testing environment. You just can't do it. You can get close, but it will never replicate that. And so again, you have to be prepared. And we've had participants who've had cardiac arrests at three kilometres into a race. That happened 10K last year for us. So you just have to always expect it. And I often say to people, "It doesn't matter how many runners there are, whether you've got one runner or you've got 20,000 runners, the risk is still there, and you have to be prepared for it."

Panos  16:42  
Yeah, absolutely. I think we can all sympathise with that even as race participants ourselves. The distinction between a casual training run and race day-- how many times have we not all gone much faster than our pace on just the adrenaline of it, right? You just shoot out the gate. You don't know what you're doing, right? You need to hold yourself back. Otherwise, you're gonna run into trouble and this is just even being reasonable. And of course, speed that you mentioned there, particularly on muscular and skeletal things and stuff like that, speed is a very nonlinear thing, right? I mean, you go 20% faster. You're not putting just 20% more strain on the body, you're putting a lot more strain on the body when you start going fast. I mean, you need to earn going fast, you can't just start going out there, right?

Natasha  17:31  
No. And that's why people should train for events. We know they don't always and some of that is unintentional, like they've been injured and, again, it's that charity effect. Like, they race for the charity and we see that a lot in the run-up to Manchester Marathon to London Marathon with people kind of coming into clinic going, "I just need to run" and I'm like, "You can't. You don't get to do it." And then, you get the people who just decide that they're actually superhuman and they're just gonna wing it. But that is why, in theory, you should follow a proper training ground that's graded, that's got sprint work, it's got distance that's gradually building up over a period of time. I mean, when I ran the London Marathon way back in 2010, I remember my training programme was at least three months long and that was on a background of doing a fair amount of running. But you just have to build it up slowly and you've got to take this seriously. And it might just be a 5K but it depends on what your baseline is. If your baseline is you can walk to the shops. Well, actually a 5K can feel like a marathon to some people. So, you're right. It's speed and it's not just about kind of going too quick at the start of the race because, often, certainly, when I did London, I remember being really frustrated at the beginning that you couldn't run because you're just surrounded by people and it's just very congested. And when those people go for a vague time, you're constantly looking at watching people, I've got to make this time up. So you then go too quickly when you can start running and then you crash and burn towards the end, which I absolutely did.

Panos  19:08  
Yeah, well, we've all been there. You cannot not be a marathon runner and have crashed through some kind of wall or many walls all in the same race. 

Natasha  19:18  
Yep. 

Panos  19:19  
It's one of those fascinating things about human nature that you can actually bring yourself to the point of actually doing serious damage to yourself and still not stopping when it comes to, like, heat exhaustion or even serious injury - like people running on broken toes or whatever that I see in some races. It's fascinating that your body just doesn't - I don't know - turn off a switch or something and help you just be more sensible.

Natasha  19:46  
Yeah. Well, certainly, with the hot people, if they're conscious when they come to us, they're very clearly confused. So, a classic is like I'll see a triathlete who's come in and they're hot and you'll be like, "Oh, do you know where you are at the moment?" They're like, "Oh, I'm at home." And I'm like, "Not really. You're in a marquee. You've been doing a triathlon." They're like, "Oh, I can't swim." And I'm like, "Well, you've just finished the triathlon." Like, they absolutely deliriously have no idea who they are, where they are, and they don't regain this bit of their memory. It doesn't come back to them, which I think is probably not a bad thing. So my theory with a lot of it is, we're a bit like herd animals in terms of mentality. Like, you're running and you start to feel ill. And, like I said, the women-- the reality is, they do tend to slow down when they don't feel very well. It's the guys that tend to push on a little bit and they push into that realm where they then become confused, and they don't know they're confused. They just follow everybody else. Everyone else is running in a certain direction, so they're going to join in. And it's really the reason we see more collapses at the finish because that's when you suddenly stop. And so people around you have stopped. Then, you're a bit like, "Well, I don't know what I'm supposed to do because I'm confused and I don't know who I am or where I am." And also, obviously, once you stop, your blood circulation drops down because your calf muscles aren't pumping that blood back up to your heart and into your head. And so they tend to drop at that point. That's not to say we don't get hot people collapsing earlier on in the route. We absolutely do. But it's the finish line that's always the busiest location from a medical perspective.

Panos  21:28  
Yeah, I read actually about what you just mentioned this thing about - which I felt in training as well - which is that when you actually stop exercising, I mean, come to a dead stop, which is what a lot of people do at the finish line, all of these big muscles stop pumping blood around and your pressure drops and all kinds of funny stuff should happen. So it's actually not very advisable doing that towards the finish line.

Natasha  21:50  
Yeah, it's funny because we've all been in a race where you're running and, in your head, you can see the finish line and that's what you're aiming for. But you still got to get home afterwards. Like, you still got to use your legs. Like, it doesn't end. It's not like you get put in a wheelchair and you don't have to walk for the rest of the day. Like, you still got to be able to move. And people often say to us all, "How am I getting home?" I'm like, "Well, you've got to get yourself out. You're medically well enough to leave." And they'd go, "Oh, but my legs are tired and we've done a marathon." It's totally to be expected. But on the blood pressure thing, that's often why you'll see the medical team at the finish line. If people are conscious and not talking absolute gibberish at us, we'll lie them down and stick their legs in the air because that gets the blood back towards their heads. And often, they're cramping at that point as well, so we'll be stretching them out a little bit. But to be honest, they need to finish the marathon or whatever distance and keep moving. It sounds really cruel, but you've got to keep moving, slowly get the body cooler, get those muscles still moving at a walking pace. You've just got to keep moving, like getting people through that finish line because, obviously, if they all stop at the finish line, they won't help you get through either. So it's got its two factors. Medically, we need to get people moving. But also from a flow perspective, you need to keep people going.

Panos  23:10  
Yeah. Well, finish-line medical tents are always a very bizarre sight. I organised a 100-mile mountain marathon back in 2016 and I think, literally, there wasn't a single participant who wasn't in the medical tent at the end of it. It was like a war zone. I thought like, "What is this thing?" It's like being in Vietnam or something - like, everyone was on a stretcher with some kind of issue, but that happens to you after 100 miles, I guess.

Natasha  23:41  
Yeah. And that's to be expected and that's in the planning. You need to know how many participants. I work out a rough percentage of how many people I think are going to be in my medical tent at any one time, and you scale your medical tent up and down based on that knowledge. So for example, Manchester Marathon that's coming up for us in April, we've got more runners than we've ever had. I'm using data from the previous two years of us managing the marathon to kind of judge how big the medical tent is. I mean, it's now fast. It's now got 32 majors bays, which is bigger than any London or any hospital in the UK for A&E. We are bigger, but that's because we know what we're expecting and it's a fast race, it's flat. But you have to take into account where your race is, and what the weather is. For us, if it was in August, for example, well, that tent, we'd easily double it. You've got to judge it and it's hard because I've been in scenarios where I've had two events on the same day that have been almost identical - one in London, one up in, say, Manchester. Same number of runners, same distance, same terrain, and one can be crazy busy and the other can be fine. And I've learned over the years that London, yes, it is known to be warmer than other areas of the UK just because of the buildings, but actually it's the buildings that cause us the problem. Like, if they run through the city, the heat that reflects off the buildings, there's just no airflow. We're not hot like we are in the States. I'm just talking, like, 14, 15 degrees, but that's enough to medically completely change the event. So previous data is always really important. If we ever get asked to do a new event, the first question I ask is, "Can I see your data in the previous years? Because I need that to get a feel of where this event is going medically so that we can actually plan it appropriately."

Panos  25:34  
So it's interesting that you mentioned these completely identical races where the only kind of obvious difference between them might be ambient temperature. When you have a hotter race, does that only come out in a higher incidence of, like, heat strokes and stuff like that? Or does it sort of, like, have not gone on other kinds of injuries and conditions?

Natasha  25:57  
Without looking at the data in great detail, I'd say it's pretty much a heat issue. I don't know because I don't track it. I don't know how many people don't complete the event. So obviously, the race organisers do. They know from chip timings who's bailing and who's continuing. I'd imagine the hotter, the more DNFs you'd get. Equally, I suppose you get more people bailing before it's even started because they look at the forecast and go, "Nope, not for me. I can't deal with that." But certainly, medically, it's more and more hot people. They're a funny one to treat because they come in looking truly awful. Like, the first one I ever saw, I thought, "Wow, you're gonna die. You look absolutely diabolical." 15 minutes later, they're sitting up talking to you. And it's really simple medicine, it's cooling them really quickly and being prepared to cool them. And I'm not just talking about a flannel or a cold ice pack. I'm talking ice water with towels drenched in this water, constantly cycling from head, chest, and legs, and you see them evaporating in front of you. That's how hot these people are. But actually, it's really basic medicine. They don't need blood tests. They don't need lots and lots of monitoring. Most of them turn around so, so quickly. The problem is they all tend to appear at the same time. And so, it feels like - the sum - it's relentless and everyone's looking around going, "God, this is horrific." And the medical team is broken really early on. But then, you start to transition into a normal race. So, say, it's been a mass start. You then start to lose the hot ones and then you gain the slower ones who are more kind of aches, pains, falls, that kind of thing. And yet, you still get the old hot person and the person with chest pain or stroke or whatever. But the hot ones all seem to appear at once and that puts a lot of capacity pressure on the medical tent. You've got to treat them and get them out as fast as you possibly can. We talked about data and looked at previous data, and you might look at race and go, "Oh, they've only treated 50 people." But what you also need to ascertain is at what point did those 50 people come in? Did they all come in together? Or was that 50 people that were really evenly spread over five hours? Because that's a very different world to deal with. If they all come in at once, then you need a massive tent. If it's 50 people with relatively minor stuff and they come in over the space of six hours, then you can absolutely condense your medical team down. You still need to be prepared for the sick one that walks in, but knowing the data on an hourly basis in relation to the start time is also really helpful.

Panos  28:34  
That's a very interesting point. What might be the causes of having those spikes in injury volume? So you'd get, like, a mass load of people coming through with a similar injury. Like, what might be causing that?

Natasha  28:50  
So with illness and the heat, it's the faster runners, simply. It's the ones at the front. So we were expecting them, we knew them. This also happens to elite runners as well. Like, anyone who watched the Commonwealth Games 2018-- there was a Scottish athlete who was in the men's race in the marathon and was in the lead, and I was there working for team England, so it wasn't my responsibility but we could all see that he was really unwell on the TV. Like, he was at the front on his own. He kept dropping to the floor and we were literally screaming at the officials to let me go out and try and deal with him because there was no one there. So it does happen at the elite level. But there are fewer elite runners, so it feels less of an impact. It's the mass participation group. In terms of the same injuries coming in, in theory, it should be just a standard normal distribution of what you'd expect of runners. Obviously, if there's a problem with the root, then we start to see things. So, for example, I asked my team at the beginning of the day to track trends, and this is something we started at Tough Mudder. It was like, "If you've seen one person that's fallen over, please document where, what mileage, what did they fall over, and why did it happen. Did they just trip over their feet? Or is there, like, a pothole that they're tripping over? And then if someone else radios in and goes, "Well, actually, I've just treated somebody. By the way, someone's just tripped over a pothole." And I said, "Oh, hang on. That's the same pothole." It means during the event, that real-time information can go back to the event team who can then go and deal with it and either cone it off or-- unlikely to fill a pothole in the middle of the event, but at least make it safe. And so, real-time data is really important. And one of the things we've started doing is having a live link between all the medical personnel on-site and event control. So they still fill in a normal medical form and they treat patients-- medically, we have to - name, date of birth, address, and all the things that the runner takes. They just literally just want to run off and I was like, "No. I need this detail." But I also get the team to fill in a Google Form link that goes to event control with really headline data like a 20 year old fell in a pothole. That's all I need to know and that comes through to me and event control, and I can look at it and start to put those pieces together and see how-- is it a cycle responder who may have seen the first person. Then, a motorbike doctor might have seen someone else. Someone at mile 20 might have seen someone who also would still fall in a mile four. But those people aren't together, so they're not going to know that there's a trend. But if I can get that data to actually know that I can look at it and go, "Hang on, we've got a problem here." And you deal with it. You're real-time managing it rather than, at the end of the event, going, "Oh, by the way, guys, we've seen this." And yeah, there will be things that crop up post-event that we hadn't put the pieces together. But if we are seeing the same injury coming in, it always raises the question of why. What's going on here?

Panos  32:00  
Hot weather, you mentioned, I think it's a fairly obvious one for people listening in, that it aggravates the risk, it elevates the risk in these kinds of conditions. I'm guessing cold weather is not as much of a challenge or other types of extreme weather like being hit by a tornado or something. Are there any kind of other types of conditions that pose particular challenges from a medical point of view?

Natasha  32:24  
I mean, for me, if I'm looking at the weather forecast per event, I am looking for 10 degrees and dry. Like, that's dreamy. That's what I really want. Obviously, on that, we need to heat the medical tent because you've got people who will come in cold and you've also got the medical team get cold as well, particularly if you're standing around. So that's kind of, like, the nice, obviously, heat we've talked about. Once we start to get colder, it depends on the environment. So for example, at Tough Mudder, we're in fairly remote locations. People have come by their car but there's not really kind of, like, warm buildings where they can go to shelter. And it's 12 miles. They're muddy, they're wet. And the colder the event, we got busier. And also, people tend to move less well and was slipping and sliding on mud. So, you'd get more fractures and things like that. So that would change that, whereas if it's a road race, say London Winter Run in February, Central London. It's a 10K. We've had a real field temperature of minus four and have medically been fine. And that's because people run, they finish, they go into a warm building, a coffee shop, the tube station that you can find places to disperse to and it's less of a problem. So the weather, again, I think, it's the environment you're in. So it's not just a straight answer of cold is bad, hot is bad. It's where are you, what shelter have you got. Like, for hot weather events, if you put in lots of risk mitigating factors, misting sprays, gazebos over the route where -- with no sides on, so they're running through some shade for a little bit, reducing the time they stood on the start line, like, get them pulsed out, get them arriving-- there's mitigating factors you can always do. And for every event I plan, I have a cold and a hot weather plan that is specific to that event. And yes, there are general principles that go across the events, but it's very different planning a hot weather plan for Tough Mudder than it is for Manchester Marathon. Like, Tough Mudder, we've got obstacles with water. And so one of the questions I would ask the team is, "If it's really going to be hot, so we're looking at 30, 35, 40 degrees which we're now getting in the UK, can we move the order of the obstacles around? So instead of having a water obstacle at the beginning, actually, can we stick it in the middle? Like, can we change the route?" You can't do that in marathon, but you can look at, actually, do we need to shorten the route in the marathon? How do we disperse people quickly at the end? How much water have we got on-site? Medically, we need more ice, etc. So the reason for a one-stock answer of what's good and what's bad is where you are and what resources you've got available to you.

Panos  35:14  
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Ok, now, let’s get back to the episode… 

Let's talk a little bit about planning. Let's talk a lot about planning, actually. I want to start us off with a bit of a philosophical question, I guess, on duty of care, which is an actually very kind of well-established term in itself in the UK - I'm not sure how popular it is as a term like that in the US. But it's basically, like, sort of the responsibility you have as a race director towards the participants who are taking part in your event. And when someone starts out their medical planning from scratch, if I did that - which I have done in the past - one of the obvious questions that come up is, "Where does my responsibility sort of end?" I mean, you can go completely overboard, I guess, and try to cater to every eventuality and every little thing. From your point of view where, perhaps, legally, but more importantly, morally, where does my responsibility as the provider of the duty of care sort of end or should end?

Natasha  37:50  
It's a good question and it's unconscious that every event has a budget and costs are high at the moment, but it's not just about that. I mean, at the end of the day, you've got to look at several factors. So for example, in the UK, we've got the NHS, National Health Service, an amazing healthcare resource, but it's under strain, it's busy, particularly at certain times of year. Be it hot, be it cold, it's under pressure. And my philosophy is, we shouldn't be putting any undue pressure on the NHS. If we are putting on a private event that is making money, not making money, it's still-- we have a duty of care not to put any undue pressure on the NHS. Now, obviously, if you've got a cardiac arrest, that patient is going to end up in hospital, whether you've got an amazing medical team on-site or an awful medical team on-site, you do everything you can and then you transfer them to secondary care which is, for us, the NHS. So that's one thing. And secondly - I say this to my medical team all the time - every patient that is there that presents-- unless it's a really bizarre event where they've not paid anything. Like, they are paying for you to be there. Like, they've paid an entry fee. So essentially, they are a private patient and we should be offering a good standard of care. And yeah, I'm not saying that if you've got a 5K for five people that you've got 20 doctors waiting for them. That's ridiculous. It has to be proportional to the distance, the risks, and the number of entrants, but my underlying principle is, I feel like I failed if the local search NHS or ambulance service are put under pressure because of failings that we've put into place. It's a failure to plan and yeah, things go wrong. We've all seen major incidents recently in the UK in the Manchester Arena bombings. There's been crushes at concerts in Brixton, stuff happens that is out of our hands as a medical team. And so therefore, yes, at that point, you have to ask for help from your colleagues in the NHS. But if it's a standard normal event, nothing is out of the ordinary, then, actually, if patients are just rocking up to NHS because the medical care isn't good enough, or we're just calling the 999 all the time to come and collect our patients away because we fail to plan that we need ambulances on site that are capable of taking patients hospital, then that's a real failure of the event, and I think reflects really badly on the medical team, but ultimately also reflects on the event. So morally, I look at the distance of the event, the risk, and I put in what I think is appropriate to not impact on my colleagues working in the NHS.

Panos  40:36  
It is not a very straightforward question. I agree. I mean, it's very difficult and it's that kind of rough rule of thumb that I was looking for, like, how do you even think about this thing? I think most responsible race directors would appreciate and would want to do quite a lot because it's ultimately on them. And I don't think any of them is under any delusions that the buck doesn't stop with them. But sort of where do you put an end to it? For instance, I expect, when you were mentioning earlier about ambulances and stuff, I don't expect even a moderate-size event should aim, for instance, to treat a heart attack, like, fully right there on the course. Right?

Natasha  41:17  
No, but they should be able to give the first-line treatment that you would give to someone having a heart attack. So firstly, you need the people there that can recognise a heart attack. First aiders, they're going to recognise chest pain, but can they determine whether it's someone who's got a really fast heart rate that's getting pain or is it an actual heart attack? Actually, it is not that hard at all. So that's kind of step one. Then you've got to have the resources to treat the heart attack. So, they to recognise the heart attack. You need someone who can give the aspirin, who can give the GTM, which opens the blood vessels. Then, you need to recognise that this is a medical emergency and you need to get them to a hospital. But certainly, in the UK, for example, if I did an event and I had a doctor on-site, and I phoned up 999 and said, "Oh, can I have an ambulance, please? I've got someone having a heart attack." They will ask me if there is anyone medical on-site and, obviously, I'm not gonna lie. I mean, yeah, we've got a doctor here. We are instantly down the priority list for that ambulance to come to us because, clearly, there's a medical professional with that patient. And if someone else is having a heart attack and there's only one ambulance, they're clearly going to send that ambulance to someone who hasn't got a doctor standing by them. So, having the resource onsite means that you should deal with it yourself, essentially. And I'm not saying therefore you shouldn't have any resource on site so you can phone the ambulance service, but one of the things-- I know we've talked about this previously. Like, one of the things I often get told is the hospital's around the corner or the ambulance station is literally over the road from us. Like, I literally don't care, so irrelevant. It means literally nothing to me. The only benefit to having a local A&E department round from you is that if you had to take someone to hospital - I mean, someone appropriate to hospital - it's less of a travel time. So you are more likely to get your ambulance back quicker than, let's say, it had to go 20 miles to hospital. But having said that, also, that's not a given. There are some hospitals that can take two, three hours to turn an ambulance around and others that are really quick. And again, that comes down to planning. You need to know that. If you're planning a medical event, you need to know your environment. So for example, when I do events in Wales, I know that, statistically, they are slower to turn ambulances around than, say, over the border into Bristol, and therefore, I need to plan that and put in maybe an extra ambulance at my event to counter that.

Panos  43:45  
I'm taking from all these that you're sort of using our ambulance and their ambulance sort of interchangeably. Would you expect that some events need to have their own ambulance on standby?

Natasha  43:55  
Oh, yeah, absolutely. Again, it comes down to the risk. So it depends on the sport. One of the things I'm really pushing for at the moment is the governing bodies in the UK-- I'd love this to be broader than this, but mini battle first is start with the UK to get national governing bodies to put in minimum standards of what medical you should have for their licenced events. So for example, in UK Athletics where I'm head of medical endurance, I am part of a team that wrote in the medical guidelines that say how many First Aiders, how many doctors, and how many nurses you need for an event that's 1 mile, 5 miles, 10 miles for 1000 people, 20,000 people, and we've written new guidance - we are waiting to publish them - that's more up to date and even more prescriptive than the 2013 data. And you can see-- if you go through those tables on the UK Athletics website, looking at it, you can see when an ambulance starts to kick in. So we're not saying, 100 runners doing a 5K needs an ambulance, but it might be if we suddenly got 1000 runners doing a 5k, well then, actually, the chance of a significant injury incident happening has gone up so, therefore, you need an ambulance. I mean, I think it's Manchester Marathon - I think we've got 17 ambulances - and eight doctors on the back of motorbikes, for example, plus all the cycle responders and the medical posts. Like, it's huge compared to if you have a local athletic club putting on a marathon for 50 people. It is still a marathon, so the risk is still there. So you scale your medical down, but I'm pretty sure our data still says you need an ambulance for that number of people for it because it's still a marathon.

Panos  45:34  
And out of curiosity, since, as you say, there is no regulation in place right now, in the UK, at least, around this, and I saw your post yesterday on LinkedIn with a petition for people to go and sign it. 

Natasha  45:46  
Yes, please sign it. 

Panos  45:47  
Absolutely, I will and it's really important for everyone to do so, I think, because again, like-- maybe some of our more libertarian listeners may think that, "Oh, whatever. Everyone's at their own risk and I'm the master of my own race, and I put on whatever." But I do think that some things need to be regulated and it's not unreasonable, as you say, to have some understanding-- it would help people out to have some understanding of basic minimum kind of medical requirements. It will also take that unknown off the race directors' shoulders. They won't have to guess and, when asked, they can say, "Listen, this is what I need to have and I have it" kind of thing. I think it's a very comforting thing to have regulation in some areas because, as you were mentioning there, the events can sort of wing it a little bit - particularly unlicensed ones, meaning not licenced by a governing body, even more so. What happens, out of curiosity, say, in the UK, if I organise a marathon and I have completely inadequate medical cover and something goes wrong? Or let's say I completely overwhelm my local NHS services or something like that. Do I get a bill? Is there a law that someone comes knocking on my door? Do I get sued by people? What happens?

Natasha  47:08  
Again, at the moment, it's such a grey area. So for those who aren't aware of the situation in the UK, to kind of put it really simply, there is no regulation of medical companies providing medical care events. So if you're running a nursing home or a hospital, you're regulated by something called the Quality Care Commission and we don't have that that extends to event medical cover. So, as simple as its description is, literally anybody-- so Panos, you today could set up a website saying our event medical cover is us. A race director could see that and go, "Oh, brilliant. Can you do a medical cover tomorrow? Right. Yeah, great." You could turn up, do the event. No one has any idea that you've got no medical qualifications, you've got no insurance because a lot of people don't even check that, no idea that you're not on, like, the sex offenders register. Like, there is no regulation whatsoever. And unfortunately, the reality in the UK is this is happening week in, week out. I know companies that have lied to premiership netball teams and said, "Oh, yeah, the team here today has got paramedics." No, they don't. They're not paramedics and we've called them out on it, and they've been asked to leave site. Like, it happens because there is no regulation and that's what my petition is about -to get regulation - because I'm passionate about it, but I think event directors and event companies need to also be passionate about it because, at the moment, you've no idea of the company you're calling out to do your medical cover is safe, appropriate, trained, has the right equipment, is it all in date, is it serviced? And also, you might be leaning on that medical team to advise you on what medical cover you need in terms of how many doctors, how many nurses, and how many First Aiders. If they're not regulated, you can't actually trust anything they're saying. Until they're caught out, like, alluded to in that example, what happens when it all gets found? Well, there's no regulation. The medical company - there's no one to hold them accountable. The race director, they're saying, "Well, I've got no guidance. I didn't know what to do." And this does happen. Now, the example I gave about the Manchester arena inquiry where we, unfortunately, had a bombing at a concert a few years ago-- now, yeah, it wasn't sport, but it's the same principles. The medical company there has been found with not put in anywhere near the right levels of medical cover. The arena has been found accountable for not ensuring the right levels of medical cover. So they are actually being held accountable for it. But when they're fined or whatever, I don't know what the outcome is other than reputational risk. But it's a real problem and people say, "Oh, how often does that actually happen?" Well, actually, the real-world experience in me and looking at some other medical companies-- and bear in mind, there are lots of really good companies. I'm not saying this is everybody, but there are companies out there that are not doing it properly, and that's scary. It's scary even if you're just a participant. Like, you want to know that the person who's there dressed all in green with paramedic blazoned across their chest is actually a paramedic, he's still on the register of paramedics, the drugs that he's giving you are out of date, hasn't been sacked from the NHS because he was dodgy. Like, you want to know that the people treating at these events are medical professionals who know what they're doing. But the way I'm coming at it at the moment is one, I'm approaching governing bodies and saying, "I will write your guidance for you. I will literally produce tables of what you need for small, big, long-distance, and short-distance. So I'll do it, be it a swim, or triathlon, a marathon." Like, I'm very happy to do it because that takes some of the guesswork out of it for the events team. But also, the UK Government needs to get on and regulate this, but that's not going to be quick. And I'd imagine that the UK isn't unique to this situation. I'd imagine there are other examples around the world.

Panos  51:18  
Yeah, I wouldn't be surprised. Can I quickly clarify something? Because you kept mentioning the whole paramedic term, and I appreciate that there might be some subtleties across parts of the world like the US and here and other parts of the world. Is a paramedic a First Aider, essentially? Is it more than a First Aider? Is he a doctor? Where does he lie basically, in that spectrum?

Natasha  51:40  
So you're right, there are different terminologies and some are what we call-- certainly in the UK, we call them a protected title and others are not. So for example, a doctor in the UK is someone who has been through medical training, doesn't have to be within the UK, but has basically gone through medical school and has a certificate. So you know I am actually trained as a doctor. Now, if you're saying your event needs a doctor, it's not as simple as saying, "Oh, good, I've got a doctor," because is that doctor one-year qualified, are they 30-year qualified? Are they actually registered to work in your country? That's something that we see quite a lot of. Also, what are they trained in? So it's great that you've got someone who's 20 years qualified but, actually, if there were heart surgeons, are they going to be any good to you who is someone who's collapsing at the finish line with hypothermia? So, doctor is a broadspectrum term but, technically, on paper, it's a protected title. Paramedic, again, is a protected title. So it's someone who has been through paramedic training. Doctors and paramedics at our events are very interchangeable in how we work because we've got a lot of the same skill sets, but we do diverge a little bit in the finer details. But again, it depends on their training. How many years qualified is that paramedic? What experience they're getting? Because if they just worked for an event medical company, they could be sat by the edge of the football pitch for half a year and not treat anyone and then you give them someone really sick at a marathon. They got that experience to deal with it because if they're not doing daily paramedic work within a normal environment, then you de-skill. And the term that's not protected is First Aider, and this is one of those super grey areas, again, within the UK, but I can imagine it's not unique to us, where it's not a protected title. So you could do a half-day first aid at work training course to be able to treat your colleague if they get a cut, and someone can then say, "Oh, I'm the first aider. I do your event cover." Now, that's not good enough. I also get a lot of people and event companies saying to me, "Oh, but we've got First Aiders within the events team. So can they just do the medical cover on the day?" No, they can't because of several reasons. One, what training have they actually got? Who's providing their equipment? It's very different to have a little first aid kit in your event office for somebody who cut themselves compared to actually treating really quite unwell people on the course. And also, if they're part of your event team, they've probably got another job to do on the day. If you're there as a medic, you are there as a medic. You're not rolling. You need to be in your medical post or on your response bike or whatever it is doing purely that role. I've talked about our equipment, but also who's insuring them. You need proper medical insurance to treat people, and it might seem an easy, cheap option of, "We'll just use the event team. They'll be able to cope with it." Try using that argument when you're in front of the coroner when something's happened. You'll get ripped to shreds. Like, a UK Athletics guidance that was written in 2013 for really small events did allow it to happen. The new guidance that's coming out says it's gone. We've taken that out. We've said, "If you're putting an event on and we are stipulating it has to have a First Aider on site, we are stipulating that it's someone that is from a medical company that you trust, you can find one, and they've got all the proper insurance, the proper equipment, and ideally going forward, hopefully, that they're regulated and leave your event team to do event work on the day."

Panos  55:21  
Yeah, I think it's a very important point. When I did my mountain race, I just felt like I wanted to do an outdoor first aid kind of course simply because I would be around. Right? But I think it's an interesting point. Of all the things that you mentioned - equipment and all the other stuff - I think the more important thing to understand for people thinking of sort of double rolling that is that you have other stuff to do. You should. I mean, if you're the race director or the assistant race director, or you're doing other things, you shouldn't have first aid. I mean, it's okay to have that skill, as I said, but you shouldn't consider yourself as a proper first aid headcount or something because you're not on the day.

Natasha  56:07  
Correct. And certainly, I would encourage event organisers to put their team through first aid training. I think that's really, really vital because, often, they are the people that find the patient. You can have lots of medics but there's still going to be gaps where we can't have eyes on every single runner wherever they are in the marathon course. So it might be your sector leader that finds someone in the marathon who's collapsed at the side of the road, and they're gonna stay with them until we can get to them. So it's one of the things I think is helpful that they are trained in basic life support, and know how to call somebody. So we've started at the marathon, giving the sector leaders some basic cooling things, just like a misting spray. It just got some bottled water in it - can be tap water in it - and they're just constantly spraying it over the participant to cool them down. It seems really basic but, actually, that started getting them better already and buys us, as the medical team, a little bit of time. Like, we're busy or we've got to come from an awkward location because the participant hasn't happened to collapse in the opposite direction to which the ambulance is pointing and we've got to turn it around and get it not go against the flow of runners to get to them. It buys us a little bit of time. So I think, absolutely, the members of the event team should be trained in first aid. I think that's vital. And to be honest, I think everyone should be trained in first aid, not just at events, but they shouldn't be the medical team. They should not count in the numbers. It's just not appropriate in this day and age. It might have been 20-30 years ago, but it's certainly not now,

Panos  57:41  
You mentioned earlier how tricky it is to go out and hire a third-party medical company. Are there any kind of, like, practical tips on making sure that you can somehow diligence the situation a little bit so, at least, you exclude the obvious red flags with the company? Or you ask some basic questions, I guess, to make sure that you're hiring someone who's skilled in that role?

Natasha  58:07  
Yeah. I mean, until there's regulation, it's tough. I mean, within the UK, there is a vague, tenuous link of registration with the CQC. So if you're a medical company that supplies ambulances, the CQC will come in and inspect you. So, like my company, for example, we don't do ambulances. We're doctors, nurses, first aiders, and we will always work with another company to do our ambulance provision, and it's just a decision I made years back when I started the company. So I can't be regulated at the moment. But if I'm picking an ambulance company to work with me, absolutely, they need to be CQC-registered. That's an England thing. If you're broader than that, though, I mean, you wouldn't hire someone in any other job or occupation without references. So if you're thinking of using a company, ask them who they've worked for, go and ask, get a reference from them and see how they interact with you. How responsive were they to emails? What were they like on the day? Did they turn up on time? Were they appropriately dressed? Did you get any feedback from participants, either positive or negative about them? Also, ask to see documents. For example, if I'm planning an event, I write a medical operations plan before the event that's really detailed. It's got everything from maps, it's got local hospitals, it's got call signs for everybody, and that's my Bible, basically. On the morning of the event, if I was suddenly really ill, I got diarrhea and vomiting can't physically be at the event, a member of my team should be able to pick up that ops plan and go, "Right, I know exactly what I'm doing." And every medical company should be producing those for an event. Be it a tiny or massive event, you need a plan. And so, if you're going out trying to find a medical team, ask to see an example of a plan and they can reduct it, they can take out the names of the company or anything that's really sensitive to that event. But just as an example, say, look, this is the work we deliver. But I think, ask around. I think that's the main thing. Certainly, in our industry in England, there are companies that, if people said to me, oh, have you heard of so-and-so, I'd be like, "Yeah, they're great. Really good experience working with them. I've only had positive things." And there'll be others that'd be like, "Absolutely not. Keep away from them." Ask. Don't just go for the cheapest quote. Cheap is not-- I mean with anything. It's not always the right thing, and it's often cheap for a reason. Is it because they cut corners? Are they telling you they're putting paramedics in and they're not? Just raise the question. I'm not saying you should go for the most expensive either because I've seen some ridiculous tenders when I've managed tenders before for events. Look at the details. Look at what information they're giving you. Check out their website. For me, I've got a bit of a red flag if the website is full of pictures of ambulances. I'm normally a little bit worried about them. Generally, the more ambulances or people standing posing in front of all their vehicles make me a little bit nervous. That's just my own personal experience, my own feelings about it. And there will be companies that have lots of ambulances on the website. They're absolutely fine, but it always makes me feel a little bit like, "Oh, God, here we go again." So yeah, just shop around and don't leave it to the last minute. If you're planning an event, please get your medical cover in place at least six months in advance because that gives the medical team ample time to staff it, write plans, have meetings with them, do site visits, and all the things that you should be doing with them. The later you leave it, the more you are likely to be scraping the barrel.

Panos  1:01:50  
So obviously, you see both sides of this because you also run a company like that yourself. When a race director goes to a company like yours and says, "I need medical cover for my event. It's a 10K. It's blah, blah, blah." From all the different little Lego pieces that you have, doctors, First Aiders, all of that stuff, how do you come up with, like, the level of provision and I know this is a kind of, like, a typical how long is a piece of string kind of question, but I'm thinking mostly of, I guess, how do the different roles in that plan work? The doctor, the first aider, the paramedic, and the ambulance, basically, like, in terms of their strengths and weaknesses, how do you use all of that resources you have to come together with a plan?

Natasha  1:02:35  
You're right. There isn't an answer. I suppose there are several things to do. I call on my experience. I've done so many different types of events now - I mean, hundreds of events - that I have got a gut feeling now of what feels right, and what doesn't, as a baseline, and I say, ask for data of previous events as well and look at the injury profile. So, for example, we've been asked to do an event potentially in two months' time, which is relatively last minute, that's a relatively large event. And I've been given data of predicted numbers per medical post, but they haven't broken it down to how serious those patients are, and that's vital. So I've gone back and said, "Look, I need a bit more of a breakdown." Again, if there's a national governing body that's produced regulations, I absolutely look at that. And to be honest, if it's a running event, even if they're not licenced by UK Athletics, I still use the standards written by UK Athletics. Bollocks, I wrote them. If it's good enough for a licenced event, it should be good enough for an unlicensed event. In terms of how it's done on the day, let's say we haven't got any information, you've got nothing. I think the first is your risk assessment. So how hot it is, how long it is, how many runners, and how many people do you think on balance are likely to be sick. As a company, I appreciate that we are different. So we are very healthcare professional-led. So if you went back 10 years ago, the majority of event cover would be very First Aider heavy with the odd doctor, the odd nurse kind of splattered around. We are the polar opposite of that because the events that we do are high risk and are either high risk because of the sheer numbers they're doing, or the distance they're doing, or the actual event itself. So we're very doctor, nurse heavy. So, we might have an event with 20 doctors, 10 nurses, and only 10 First Aiders. Like, it's completely the other way around. But that is based on supposedly our knowledge of sport and events, both from experience, but also-- like my training is sports and exercise medicine. There aren't many of us out there who are literally what we learn for four years in our training as post-becoming doctors. So it just used that kind of experience and it's hard though. That's why I am pushing governing bodies to kind of let me write baselines so that you can use them and go, "Okay, I'm doing an open water swim. What should I have for my 10K open water swim in February? If there's a table that you can look at and say, in ideal weather conditions, this is what you should put in. Then you've got that as your template and then you go, "Well, actually, it's going to be really cold on that day, I need to up it from that level." But that's my gut feeling. And that's where you as race directors have to trust your medical teams. And that's why picking your medical team is absolutely integral.

Panos  1:05:34  
And once that medical team is picked and hired, and obviously I provide them all the information they may need to come up with a plan, is there anything else remaining for me, the race director, to do? Like, I don't need to be having my own kind of, like, medical equipment provisions or anything like that, or first aid kits or even simple stuff, do I?

Natasha  1:05:53  
No. I mean, like I said, if you've got an event team who are first aid trained, then it's worth giving them a little bit of basic first aid equipment. But bear in mind that they shouldn't just see and treat a patient on their own. No, they should start treatment and then get back up from the medical team coming in. If it's an event with a first aid room that's already there-- for example, I work for England netball. I was in the Notting Motorpoint Arena recently for an England netball match. There's a first aid room there. So I want to know pre-event what's in that room? Can I use it? Is there a clinical waste bin? Is there a sink? So if you've got existing infrastructure, then pass that information over to your medical team. But in theory, you are bringing in a medical team who should be self-sufficient. Granted, I will ask for help with generators, marquees, tables, and chairs because, funnily enough, I don't have a 30-by-25 metre marquee in my house that I can use for Manchester Marathon. Of course, I'm going to ask the race director if they can assist with that. So there's always a discussion of, "Okay, can you provide the radios or provide this?" And that needs to be clear in the tendering process. So if I'm doing a quote for an event or writing my resourcing, I'll put the bottom key items that I want the ambulance provider to bring, like, the ambulances and any gases or if they need, like, really specific stuff, I'll stipulate it. And then at the bottom, I'll put a list of items that I would like the race to provide like radios, ice, this amount of water, this number of tables, this number of chairs, and you have to be upfront from that from the beginning. And yeah, it means that I'll tender for events and I'll do a whole load of work. It might take me two days to put a proper document together and we don't get the event, but you've got to be upfront from the beginning and say, "This is what it's going to take for us to deliver this event for you."

Panos  1:07:44  
And I guess the lesson there for the race director is that's also the level of detail you should expect in a tender from a company. I think people should be aware of that. And it could be well-meaning, but you don't want sort of, like, grey areas and stuff left out of the tender. Like, you want everything specified, who brings what, what's expected of everyone. So it's all sort of just for good order sake, just all taken down, sort of, in writing so there's no kind of ambiguity around stuff.

Natasha  1:08:16  
Yeah. Because you might go, "Oh, this company looks cheaper, we'll use them. Now, everything else looks good. Everything they told us about them, their references are fantastic." And then, three weeks before the event, they're like, "Oh, we need this marquee" and they're like, "You never said that." And now that's suddenly a lot more cost and you've got to sort it and arrange it. It needs to be upfront. And equally, I told people that when we actually write you a medical operations plan, "Please, can you actually read it" because there will be detail in there that you might not have clocked in. And I've had this before. I've had it at an event where it was all in the tender, and I was like, "Okay, we need this size medical post to be at the finish." It was a cycling event. I want it right by the finish line. I want to end here. We've got three weeks out and they phoned me and went, "Oh, we didn't know we were fighting all the medical structures." Like, it has literally been in everything from the very beginning. You've had versions one to six of the medical plan. It's been in there since version one. It shouldn't be a surprise. I've told you. I can only tell you a certain number of times. It's up to you to read it. But we don't write the medical plans purely for the medical team only. It's for the event as well. And so the event needs to read it. And I share those medical plans with the statutory services around me. So if I'm doing an event in London, I send my medical plans to London Ambulance Service so that they are aware of the event. I send it to the hospitals that are potentially receiving hospitals because they might want to put more stuff on that day, knowing that, actually, they could be a lot busier. So the plan, yeah-- it's the manual for the medical team, but it's for everybody else as well. And so, the moment I write a plan, I share it with everybody and go, "Can I have your input for anything that changes? It's similar to last year, but this has changed. Can you make sure that this is all right?" 

Panos  1:10:05  
And the emergency services that you're sharing those plans with, are they generally welcoming of them? Or would they have a person who's, like, "Thank you."? Is there a process? Is there, like, a structure there on the other end of the emergency services for someone to take in those plans and take the appropriate action?

Natasha  1:10:23  
Certainly, in the ambulance service, yes. I think this is a general term across the UK, but I think they call resilience planners or emergency planners within the ambulance service. For London, there are several of them. London's broken up into regions. And I'd send it to Matt, if it's a central event, for example, and he comes back to me, and every time he's like, "Thank you. Really appreciate it." And we've got such a long working relationship now. He doesn't request to be on everything, he's like, "Yeah, it's fine. It's you. I'm quite happy." I don't know what conversations he has with other medics, but it's always very positive. The hospital is always a harder one to do because there isn't necessarily one person who takes the lead within the hospital for me to send the email to. So what I normally do, if I don't already know, is I'll phone up the A&E department and ask for the secretary of the lead consultant because, at the end of the day, A&E is going to take the battering. They're the ones that need to know about it. And I get their email address and I send an email, and I will often be like, "If there's anyone else you want me to share this with, please let me know." Yeah, every year, I have to go through the process of checking again because they often left or they're not going to lead and it's somebody else, or they change the domain name on the email addresses and they're all bouncing and you just have to-- yeah, it's time-consuming. But again, that's the role of the medical team. They should be doing that. That is something that I spec as part of my time because I know it takes time, particularly if you've got six or seven receiving hospitals around you, you've got to find every single one of them. Anyone who's found a hospital switchboard, you'll realise that it's not a quick process to get through to the person that you actually want to speak to, as you keep repeatedly being put through to the canteen when you actually want the A&E department. But again, it's something that I do is vital.

Panos  1:12:07  
Let's talk participants for a sec. Two aspects of that. The first thing I wanted to ask is about collecting participant information. Again, there may be some slight differences, particularly because of privacy laws between UK and US and other parts of the world. But as an event director for these kinds of races we were putting on, what kind of information should you look to collect from participants? Like, you don't want to be going, again, overboard - like, useful, necessary stuff. What kind of information would you want to collect? How would you collect it? How would you ask it? At what point? How would you keep a record of it? And how do you actually retrieve it when you need it and use it?

Natasha  1:12:51  
So there are several ways this process currently happens at the events I work at. I think in terms of how the data is collected, it's all collected when they sign up for the event. So they go online, register for the event, and it asks them to put in some basic medical details. And what I'm interested in is I want to know if they got any significant medical illnesses. So I don't want to know that they had a cold last week, but I do want to know that they had open heart surgery two years ago, or they've just had cancer treatment, or they're asthmatic. It should be things that stick out in the person's mind. They shouldn't have to sit there going, "Oh, do I have this condition? Should I write that down?" It should be big stuff. Also, the big one for me is allergies. So, are they allergic to anything? Because people are allergic to medication and the last thing we want to do is to make someone worse. And we use this data. So, prime example, London Winter Run this year, we had someone who was unconscious during the event. First thing I did was get the medics on the scene and confirm the running number, and then I looked up that running numbers details and was able to confirm that they declared that they had no medical information. So they had said there was nothing wrong with them. That doesn't mean they don't, just means they didn't bother to fill in the bit to say, no, they didn't have anything. It was just blank. Whereas other times, you get detailed information. The other thing I get them to also check on the scene is a lot of events have the ability to write medical information on the back of the bib. So he pulled off the runner's number and, on the back of it, it had her name. So that was the other thing that helped me to confirm that the runner number and her name were the same person and she hasn't registered and then got some of her friends to run for her because she couldn't run because it's really important that we know it's the right person. And in terms of actually how I see that data, basically there are two ways it's done to me - either the event team either email it to me with a password protection on it on the day, but they will normally send it to me about a week out as well just to have a highlight read through it, or I'm giving you an encrypted memory stick on the day of event control so that I've got access to it. The third option is I don't own the data. Someone else has it on their laptop from the event team, and I will go up to event control and go, "Can you look at runner number 1234 and tell me who they are, and what's wrong with them." And then obviously, it's all linked to the next of kin details as well. So if we've got cardiac arrest or something like that, my role during that is to find the next of kin as well. So we use that data, and that's why it's so important that it's the right person because I don't want to find the wrong person. And I will often ask the medical team, "Is there anyone around that person who's collapsed who appears to know them to see if they can confirm their name just to make sure that it is absolutely the right person that is registered on our system as being the runner?" 

Panos  1:15:42  
A couple of races that I used to do, particularly, a few years back in Europe, they used to also insist, particularly, marathons on receiving a medical certificate, which most of the times meant you had to have, like, a doctor or something do some kind of examination on you and sign it. Some of them were quite demanding of being seen by a heart specialist or something or a cardiologist of some sort. And I've always wondered, particularly since I've seen how I was examined in some of those cases, very kind of, like, "Yeah, you look great." Whatever. A bit of a rubber stamp. Do you think this adds an extra layer of protection, I guess? Does it help at all putting participants through that kind of process?

Natasha  1:16:33  
Gut feeling, no. Yes, it probably does pick up the odd person - maybe one in 500,000, people who didn't know that they had a funny heart rhythm, and it kind of picks it up. And I know of an athlete who recently had a medical to go to the States to swim for university or college - I think they call it other - and he was found to have a dangerous heart rhythm that actually stopped him from swimming. So medicals can pick up things. Having said that, first question is who's doing the medical? So it could be a GP or a family medicine doctor - I think it's called in the States - or it could be a sports medicine consultant. So, you're going to get differing areas of knowledge of who's doing it. I know, certainly, in the UK, there are a lot of GPs that will not sign these forms because, "I'm not trained in this. This isn't my remit. Why am I signing off? Like, I don't want the risk of it." So I don't think it adds a great deal. What I think is more important is that we implore participants, if they've got a concern like, "Should I be running or can I do this?" to contact the event, who can then contact the medical team and ask them. And in certain events, I will get a couple of emails from-- they just had a heart attack two months ago. Are they okay to do this 10K? They're only going to walk it or whatever. And often, I will say, look, actually, you are a little bit high risk. Like, we can't stop your racing, but it would make everyone feel a lot happier if you could get a letter from your surgeon or your cardiologist to say, "I'm okay with this." We can't stop them in the UK saying you can't compete. That's not something we're allowed to do over here. But certainly, I would rather the medical team be prepared and aware of that rather than try and keep it kind of brushed under the carpet and not let us know. Again, another example of it was athletics - British Athletics Championships indoors a few weeks ago. One of the athletes came up to me before the event and went, "I've got a bit of a problem at the moment. I keep collapsing in races. It's being investigated, but I want you to be aware of this." She did collapse and we were absolutely ready. I mean, we're already ready there. Anyway, we've got all the kit wrap but we're, literally, gloves on stood by the edge of the track ready.

Panos  1:18:54  
Is that an elite? 

Natasha  1:18:55  
Yeah. It's elite.

Panos  1:18:56  
That sounds almost like Monty Python-esque. I keep collapsing at races. I mean, okay, don't race any more!

Natasha  1:19:04  
I mean, she'd been told that, because it was all undetermined, they said she could still race. So I'm not going to stop her, but we very much appreciated the heads up and we were prepared for it. We weren't shocked and kind of like, "Oh my god, someone's unconscious on the track." We were expecting that it's okay. None of us looked stressed by it because it was something we were all very aware could happen. So, we would rather people gave us that heads up and said, "I've got this problem. Here's a letter from my surgeon or my doctor saying actually, it's fine." But I think blanket routinely screening unless there is an absolute proper process for a very specific form and it's seen by a Sports Medicine consultant who's overseeing it, and it's just not viable. I mean, there's just not that many of us around. It'll make us very busy. It'd be financially great, but I think it's not a long-term solution for events to do that.

Panos  1:20:04  
Yeah, absolutely. I mean, I always suspected that it was a little bit of a box-ticking exercise, to be honest. Maybe in some countries like I raced in, I did the road marathon a while back. Coming from Greece myself, I know how regulation works in South Europe. I think it's a lot of, like, arse-covering, to be honest. Like, what are do you after me for? I checked it and people just basically want to shift the responsibility to someone else. I want to wrap us up with a little bit of a look on-- which is something, again, maybe your third-party medical provider is doing at recording the incidents that happened during the race? Is there, like, a standard to that, or is every company would have their own way of recording or even the same level of detail that might go in so that you have a log after the race of everything that happened and maybe kind of learn from it and improve?

Natasha  1:21:00  
Yeah, I think there should be a standard. In short answer, there isn't. I, for example, take writing the medical report quite seriously. For me, it is a document that accounts for what's happened, but it's also a learning for next year. So I will summarise how many medics were there, where they were. Even though it's in the medical plan, it might be different on the day. Since you wrote the plan, three days pre-event, you might have known that the weather can be really, really hot and, suddenly, you've added a load of extra medics. So, that needs detailing equally. People can be ill on the day. So you need to know whether you are short of people and how you manage that. So I will document every detail, what went well, what didn't go well, do we need more tables next year, more chairs, better lighting. Was the speaker too close to the medical tent for the sound system for the finish line that we couldn't hear? That means that, next year, when they're planning the event, they can look at how they're doing the sound rigging. I kind of break it down into categories like course posts, finish posts, and stewarding. Did we have any problems with stewards? Sometimes, it can be a brilliant experience. Other times, it can be not, and that's important to feedback. And obviously, casualty data. So how many people were treated in each medical post? Were they all minor? Was there anything serious? Where did they go to hospital? If they did, do we have any follow-up information? Often, I can't ring the hospital and say, "Oh, we took Jane Smith to hospital on Sunday. Can you let me know what happened?" I'm not allowed to know that information. So we have a system. We give a business card to any person going to hospital. And if they're really sick, we'll give it to the friend or the relative travelling with them, and it basically just says, "We would love to know how you get on. Please get in touch." And it's got my details. And about 20% of the time, we get a lovely email back saying, "Thank you so much." Really great experience just to let us know this is what they found. Often, I'd get, "Hey, could you also send me a medal in a T-shirt? Because I didn't cross the finish line." Well, yeah, we'll arrange that.  We're sort that out. But I think a medical report is as important as the medical plan. Every time I do a new event or a repeat event, I go back to similar event medical reports and trawl through them and what did I learn? What can I put in? And it just makes it so much easier when you're writing the medical plan for the next year because you're like, "Okay, this is what went well, but this is the stuff we need to focus on. We didn't have enough ice or, actually, the towels that turned up were actually blankets and didn't absorb much water for cooling. For next year, we need proper towels, etc." And if you're doing lots of events, you don't remember this detail. It has to be written down. How big or small your event is, you need a medical report. And if it's a small event and you treat one person, then you know, half the pages, you will be literally just detailing the event, where you were, and what the weather was. That's the thing I document in the medical report. Like, I take a wet bulb globe with me. I measure the weather. Several times throughout the day, I'll document that because that affects your data interpretation. And so yeah, every event should have a medical report. That, again, when you went back to ask about how you get a medical provider, ask what kind of detail you get in your medical report and see what comes back.

Panos  1:24:12  
Yeah, and I completely agree with the sentiment that I don't think you should even leave that for later or much later, to be honest. I mean, obviously, you want to treat someone and then probably make some notes, but you jump even on the most basic business call. And if you don't take notes, the minute you hung up, you've lost half of the stuff you were discussing. Plus, time tends to change your perception of what has happened. I mean, this is very well documented in, like, human psychology. You can be trusted to even remember or take notes of what may have happened, like, a day or two days ago. And that thing with a business card, actually, is an awesome little touch that I think lots of people would appreciate, both for the practicality and for the gesture of it, right? 

Natasha  1:24:55  
Shows that we care.

Panos  1:24:56  
Yeah, exactly. Exactly. 

Natasha  1:24:57  
Yeah. And you're right. If I don't write a medical report quickly, you forget the information. So I write it as I'm going around, even on the setup days. Like, the event might be on a Saturday or Sunday, and I'm setting up the marquee on Thursday or Friday, I will write notes as I'm going along. Tables and chairs arrived late, this delayed this. Therefore, next time, we need them earlier, etc. During the event, I'm still writing notes. Like, every time something happens, I'll just jot something down on my phone to say, "Okay, this patient went to this hospital." And yeah, we've got a log that's tracking that in event control anyway, but it's just easier just for me to write it down and then I've got it. And I'll submit every medical report unless it's, like, from a world championships and it's like 20 pages long. Like, most events, the vast, vast majority, I've submitted within two days because I want it done because I'm already thinking about the next event anyway. I've already moved on. Medical report writing for me is the close of the event, unless we've got, like, coroner's or something else that we need to do. It's the end. Move on. I think the coroner will also offer medical reports as well.

Panos  1:26:01  
Knock on wood that there needs to be a coroner involved in any of this. 

Natasha  1:26:05  
It happened once.

Panos  1:26:06  
It's happened, actually, to a couple of people I know. It actually happened - Matt Trevett might be listening to this - in, I think, his inaugural event and it can be very, very shocking. 

Natasha  1:26:19  
It's traumatic.

Panos  1:26:20  
It's a numbers thing. I mean, it might happen to you. If it's your first event or your 100th, I guess, not something you want on race day. If people want to maybe follow up with you on some of these things we've been discussing or have some questions-- I know that we've answered lots of questions, but particularly around the point of hiring medical staff and things, I think we may have raised some concerns and questions as well. If people want to maybe reach out and have a chat, how can they reach you?

Natasha  1:26:51  
Best probably by email because, as you alluded to at the very beginning, I have many jobs and I'm all over the place. And often, with patients, I can't answer my phone. Drop me an email. I'm very happy with my email address to be shared or through the sports medics website. If you go to a Contact Us form on there, it comes through to me. Very happy to answer questions because, I mean, I think, as you can probably tell because I don't shut up about it, events are my passion. It's what I love about all the forms of medicine I've ever worked in. I just want to make it better and to make it right. And if that's my legacy in this world, then absolutely, I will do it. Going back to my petition, please, everyone sign the petition. Quite happy to share that link out. Events need to do better, simply, and it is our responsibility as medics and race directors to do that. And it's everyone's responsibility, and we just need to get it right. Do it right.

Panos  1:27:46  
We are going to put the link actually. We should include the link to that petition in the show notes and I'm going to add your email there. You're also contactable. Obviously, you're on on LinkedIn, but that took us a few months to connect through that. So I don't-- 

Natasha  1:28:00  
Not the quickest. 

Panos  1:28:01  
Yeah, not the quickest. With you, definitely not the quickest.

Natasha  1:28:04  
Emails, I'm really quick. LinkedIn, definitely not.

Panos  1:28:08  
Absolutely. As is everyone, I guess. So yeah, listen, I think for such a relatively stiff topic. I think it was very thoroughly enjoyable - coroners aside and all that. I want to thank you very much for your time, Natasha. I really appreciate it. I think we've covered lots of ground with some very interesting tips. Even if some of the discussion was a little bit more UK based, I think there are lots of stuff there that apply. So thank you very much for taking the time to speak with me.

Natasha  1:28:33  
No, loved it. It's been great speaking to you. And if there's anything I can do to help, just shout.

Panos  1:28:38  
Absolutely. And thank you very much to everyone listening in. And we'll see y'all on our next podcast.

I hope you enjoyed today’s episode on race medical planning with SportsMedics’, Natasha Beach.

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