American Journal of Emergency Medicine xxx (2014) xxx–xxx

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American Journal of Emergency Medicine

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Brief Report

Injury and illness sustained by human competitors in the 2010 IditarodSled Dog Race☆

James W. Gallea, MD, George L. Higgins III, MD⁎, Carl A. Germann, MD, Tania D. Strout, PhD, RN, MSdDepartment of Emergency Medicine, Maine Medical Center, Portland, ME 04102, USA

a b s t r a c ta r t i c l e i n f o

☆ The authors have no commercial associations or soura conflict of interest. This study did not receive external fsubstantive contributions to the study, and all auconclusions. Reprints are not available from the authors⁎ Corresponding author. Tel.: +1 207 662 1452; fax:

E-mail address: higgig@mmc.org (G.L. Higgins).

http://dx.doi.org/10.1016/j.ajem.2014.02.0180735-6757/© 2014 Elsevier Inc. All rights reserved.

Please cite this article as: Gallea JW, et al, InMed (2014), http://dx.doi.org/10.1016/j.aje

Article history:

Received 15 January 2014Received in revised form 12 February 2014Accepted 15 February 2014Available online xxxx

Objective: Alaska's 1049-mile Iditarod Trail Sled Dog Race is the world's longest sled dog race and the flagshipevent in the sport of sled dog racing. Race conditions are typically harsh. Physicians are not officially enlistedto care for human competitors. Instead, medical needs aremet through an informal system of volunteers, localhealth care providers, and a fleet of bush planes. The goals of this study were to identify the types of humaninjury and illness experienced and the methods by which these conditions are treated.Methods: Competitors in the 2010 Iditarod were surveyed at the halfway point and at the finish of the race.

Survey elements included specific types and frequencies of injuries and illnesses, and the sources and typesof treatments.Results: Seventy-one teams entered the race, 62 participated in the halfway point survey, and 55 completed thefinish line survey. Ninety-nine injuries were reported by 42 (68%) of the survey respondents. Frostbite was themost common injury, occurring in 20 (31%) of the respondents. Musculoskeletal pain was also commonlyreported. Two mushers sustained closed head injuries, with 1 requiring evacuation. Twenty-three mushers(37%) reported an acute nontraumatic condition, most frequently an upper respiratory infection (9 respon-dents). Inmost instances,medical conditionswere self-managed. Race veterinarians and support staff, aswell aslocal village clinicians, administered the majority of care, typically wound care or oral antibiotic administration.Conclusions: Most injuries and illnesses sustained by mushers in the Iditarod are minor and self-treatable. Life-threatening conditions are rare, and the need for an organized medical care system seems low.

© 2014 Elsevier Inc. All rights reserved.

1. Introduction

The Iditarod Trail Sled Dog Race is an extreme, cold weatherendurance contest. This annual event typically draws a field of between70 and 95 teams consisting of a human “musher” and 16 sled dogs.Teams race around the clock, stopping for brief rest breaks and mealsevery 6 to 10 hours plus 1 longer, 24-hour break at 1 of the 21 check-points along the trail. Each checkpoint is staffed with race officials aswell as a teamof veterinarians. No assistance is provided to these teamsduring the competition, unless an unexpected and potentially seriousevent develops. Teamsmay spend 2 weeks on the trail before finishing.

Veterinary research has been conducted on the canine athletesthat compete in this race, but considerably less research has beenpublished on the human competitors despite this event offering anexcellent opportunity to study the effects of extreme climates onendurance athletes. Published studies on human competitors in thisannual event have primarily focused on the functional traits ofmushers, especially the stressful effects of sleep deprivation, physical

ces of support that might poseunding. All authors have madethors endorse the data and.+1 207 662 7025.

jury and illness sustained bym.2014.02.018

exertion, and cold exposure on behavior, metabolism, body mass,and hormonal physiology [1-5]. Although anecdotal reports suggestthat physical injuries and illness do indeed occur during the Iditarodrace, we could identify no systematic published data specifically ad-dressing this issue. Our investigation is meant to serve this purposeand identify the sources of treatment used.

The primary objective of this study was to contemporaneouslysurvey the mushers competing in the 2010 Iditarod Trail Sled DogRace, both at the midpoint and at the completion of the event, todetermine the frequency, nature, and severity of the injuries andillnesses sustained. In addition, we were interested in identifying thesources of medical care used by the competitors when needed. Finally,we were interested in examining in detail any emergent medicalevacuations or search-and-rescue operations activated during thisrace, with focus on the equipment and personnel involved and thespecific circumstances surrounding these operations.

2. Methods

To determine the scope and frequency of injury and illness en-countered by Iditarodmushers, competitors were asked to voluntarilyrespond to a survey. Identical surveys were administered during therace at the halfway point as well as after the race at the finish linein Nome. This was done to improve data accuracy given the length of

human competitors in the 2010 Iditarod Sled Dog Race, Am J Emerg

Table 1Injuries sustained by the competitors of the 2010 Iditarod (n = 62 respondents)

Acute orthopedic injuries 30 (30%)Acute neck/back pain 8Sore hands/feet 7Acute knee injury 6Muscle strain/tear 5Ankle sprain 2Acute shoulder pain 1Hand fracture 1

Frostbite 20 (20%)Frostbite, hands 9Frostbite, feet 7Frostbite, face/nose 4

Acute traumatic injuries 18 (18%)Contusion/abrasion, upper extremity 6Hand laceration 3Contusion/abrasion, lower extremity 2Closed head injury 2Minor abrasions, not to extremity 2Nasal fracture 1Chipped teeth 1Hot water burn 1Diplopia (after head injury) 1Acute or chronic back/neck/extremity pain 14 (14%)Other acute exposure, related injuries 13 (13%)Numbness, fingers/toes 6Finger splits 6Frozen corneas 1

Miscellaneous injuries 4 (4%)Muscle cramps 2Groin pain 1Skin chafing 1

Total 99

Table 2Illnesses sustained by the competitors of the 2010 Iditarod (n = 62 respondents)

Acute illness 21 (75%)Respiratory infection 9Extreme fatigue 3Nausea/Vomiting 3Diarrhea 2Dehydration 2Dental pain/infection 1Syncope 1

Chronic illness 6 (21%)Asthma/Reactive airways disease 2Insulin-dependent diabetes 2Hematologic malignancy 1Chronic muscle cramping disorder 1

Miscellaneous illness 1 (4%)Lower extremity edema 1

Total 28

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the event. The survey was administered by 2 emergency physicianswho are both veteran Iditarod competitors. Institutional review boardexemption was awarded by the Maine Medical Center Research Insti-tute, Portland, ME.

The survey asked mushers to identify any injuries or medicalillnesses that were experienced during the race and to describe theseconditions. Injuries were categorized as either orthopedic or non-orthopedic traumatic. Respondents were then asked to describewhether each condition was acute or related to a preexisting con-dition and to rate the impact each condition had on their ability tocompete in the race. This rating was done on a 1-5 scale, with 1representing no impact and 5 representing a condition that led to themusher withdrawing from the race. Lastly, respondents were askedto identify any and all sources of treatment used for each condition,including self-administered treatments.

Data were categorized by race bib number, and conditions re-ported at the halfway point survey were not counted a second time atthe finish survey. Data were entered into a Microsoft Excel (MicrosoftCorp, Redmond, WA) spreadsheet program for organization andanalysis. Summated data are presented as numbers and percentages.

3. Results

Seventy-one competitors entered the race, and 55 (77%) reachedthe finish line. Overall, at least 1 survey (halfway point or finish line)was completed by 62 (87%) of the 71 competitors. Of the 55 finishers,45 (82%) completed both halfway and finish line surveys. An ad-ditional 4 finishers completed the survey at the finish line only,yielding an overall response rate of 49 (89%) of 55 finishers. All surveyrespondents, whether they finished the race or not, are included in thedata provided. In addition, each injury was counted separately, even ifa musher sustained 2 or more injuries in a single accident or, in thecase of frostbite, if 2 different locations on the body were involved.

Overall, 99 injuries were reported by 42 (68%) of the surveyrespondents (Table 1). The most injuries reported by a single com-petitor were 5. When grouped together, orthopedic conditions com-prised the most common acute injury type, accounting for 30 (30%) of99 injuries. Frostbite was also a common injury, representing 20(20%) of the reported injuries. Sixteen (80%) of 20 frostbite injurieswere to the hands and feet. Other acute nonorthopedic traumaticinjuries comprised 18 (18%) of the reported injuries. Most wereminor and did not have a significant or race-ending impact on themusher. However, 2 mushers sustained closed head injuries, with 1also sustaining metacarpal fractures and requiring evacuation. Thisincident is discussed in further detail below.

Twenty-three mushers (37%) reported a total of 28 illnesses(Table 2). Twenty-one (75%) of the illnesses were acute. Upper res-piratory infection was most common and was reported by 9 (15%) of62 respondents. Six respondents (10%) reported chronic illness, withasthma and insulin-dependent diabetes each being reported by 2mushers. Notably, these mushers all rated these chronic diseases ashaving only minor impact on their ability to compete in the race.

Overall, the impact of injury or illness on the mushers' ability tocompete in the race was deemed to beminor (Figs. 1 and 2). However,the injuries that were reported as having a significant impact onmushers' ability to compete were knee sprains [2], frostbite [2], upperextremity contusion [1], thumb pain [1], finger splits [1], and musclecramps [1]. The 2 illnesses reported as having a severe impact wereboth upper respiratory infections. A singlemusher sustained 2 injuriesthat were each classified as race ending.

For both injuries and illnesses, the majority of care and treatmentwas self-administered. Other sources of care included race veterinar-ians (6 instances of care), physicians (5 instances), fellow competitors(4 instances), other race personnel (2 instances), village health aides(1 instance), and dentists (1 instance of care after the race finish). Theveterinarians assisted in the treatment of 4 injuries and 2 illnesses.

Please cite this article as: Gallea JW, et al, Injury and illness sustained byMed (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.018

Treatments provided by the veterinarians included antibiotics andwound closure with sutures.

A single medical evacuation was required. This musher sustained asignificant closed head injury and a fractured hand. He was initiallyfound and treated by a fellow competitor who happened to be amedical student. Other competitors were able to notify race officials atthe nearest checkpoint. A privately owned ski plane capable of landingin the tight mountainous terrain was in the area. The pilot ferried theinjured musher to the nearest checkpoint, where he was transferredto one of the Iditarod's ski planes and flown directly to Anchorage.Fortunately, evaluation at the receiving hospital revealed no signif-icant intracranial injuries.

4. Discussion

Alaska's 1049-mile Iditarod Trail Sled Dog Race is the world'slongest sled dog race and the flagship event in the sport of sled dogracing. The course originates near Anchorage, crosses the Alaska

human competitors in the 2010 Iditarod Sled Dog Race, Am J Emerg

Fig. 1. Number of reported injuries by severity.

3J.W. Gallea et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Mountain Range, traverses the desolate interior of the state, and thenfollows the Yukon River before crossing a smaller mountain range andfollowing the Bering Sea coast to Nome (Fig. 3). Conditions arevariable but can be severe, with temperatures reaching lows of−51°Cand wind speeds recorded in excess of 128 km/h along the trail(personal experience and knowledge of the first author J.W.G., whohas competed in this event).

Our survey data suggest that most mushers incur some type ofacute injury while competing in the Iditarod. These injuries can beassigned to 3 general categories: orthopedic, exposure-related, andnonorthopedic trauma. Studies of traumatic conditions in otherwilderness activities have been published, and these reports suggestthat sprains, strains, and soft tissue injuries are the most commoninjuries [6,7]. Consistent with this, nearly half (48%) of the injuriesreported in our survey were orthopedic or nonorthopedic trauma innature. Notably absent from the list of injuries reported in the surveywere bite wounds, despite the presence of more than 1000 dogsduring the event.

Based on the reported impact these injuries had on participants'ability to compete, it appears that most injuries were minor. Only 4respondents rated orthopedic injuries or nonorthopedic trauma ashaving a severe impact on their performance. In part, this may beexplained by the high level of both experience and physical fitnessof the mushers, although this study did not examine the effect ofthese variables. Interestingly, very few mushers wear any kind ofdedicated protective equipment such as helmets or padding.Although not part of our survey, one musher in the 2010 Iditarodwore hockey pads over his shoulders and upper body during the firstpart of the race when the trail crosses the Alaska Mountain Range.Otherwise, most mushers simply wear highly insulated clothing in-cluding face masks and goggles depending on conditions. This pro-

Fig. 2. Number of reported illnesses by severity.

Please cite this article as: Gallea JW, et al, Injury and illness sustained byMed (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.018

bably provides some degree of protection from trauma by virtue ofthe layers of soft insulation.

Despite the advanced cold weather clothing, exposure-relatedinjuries were also very common in our study population, comprising1 of every 3 reported injuries. Not surprisingly, most of these injurieswere to the hands and feet. Similar to mountaineering and polarexploration, the Iditarod and other ultralong-distance sled dog racesrequire participants to spend extended periods of time in subfreez-ing conditions. Adding to the challenge is sleep deprivation and thedegree of physical exertion required of the single human member ofeach team. All dog care and feeding, as well as equipment main-tenance, are the sole responsibility of the musher. Consequently,hands and feet appear especially vulnerable. Presumably, painfulsplits in fingertips and paresthesias of fingers and toes are alsorelated to cold weather exposure based on the anecdotal reports ofthe mushers.

Maintaining adequate hydration is an important aspect of anyathletic endeavor, and this is a major challenge for Iditarod mushersgiven the difficulties in preventing water and electrolyte solutionsfrom freezing while on the trail. There are numerous adverse con-sequences of dehydration, including an increased risk of exposure-related injury andmuscle cramping. However, only a single participantreported muscle cramping as an injury.

Despite sleep deprivation, physiologic stress, cold weather, lackof running water, and suboptimal sanitation along the trail and thefact that mushers often prepare their own food near the raw meatsand fats being fed to the dogs, illness was significantly less prevalentthan injury in our survey. Only 21 acute illnesses were reported.Predictably, respiratory and gastrointestinal infections comprised67% of acute illness. Interestingly, only 3 participants reported ex-treme fatigue and 2 participants reported dehydration as illnesses.Overall, the impact of acute illness on respondents' ability to competein the race seemed mostly minor.

Most injuries and illnesses were self-treated. Given the minorimpact most conditions had on the mushers, this is not surprising.However, the lack of a formal medical system to care for mushersalong the race trail also probably accounted for this observation. Inaddition, although not a part of themandatory equipment required byIditarod rules, most mushers carry some sort of first-aid kit that oftenincludes bandages, tape, ACE wraps, and basic over-the-countermedications (personal experience and knowledge of the first authorJ.W.G., who has competed in this event).

The Iditarod has a large veterinary staff, but no dedicated physi-cians. Some race volunteers and officials have varying degrees ofmedical training ranging from emergency medical technicians toemergency physicians with wilderness medicine experience. How-ever, they are not dedicated medical personnel, are often not licensedto practice in Alaska, and are usually serving other roles. Theyprovide medical care on a coincidental basis as “Good Samaratins.”The only licensed and trained medical providers along the race trailare the health care workers in the Alaska Native villages the racepasses through. The larger villages often have a physician assistantor nurse practitioner, but smaller villages usually only have a villagehealth aide with training equivalent to an intermediate emergencymedical technician.

In contrast, each of the Iditarod's 21 checkpoints has a team of upto 6 veterinarians who are available around the clock while teamsare passing through. They are well equipped to manage a largevariety of emergency veterinary medical conditions. Supplies includeintravenous fluids, antibiotics, anesthetics, and wound care equip-ment. Most of these supplies are actually labeled for human use.Given the paucity of medical providers relative to veterinarians, it isnot surprising that the veterinarians provide as much musher careas physicians and village health aides combined. Based on our surveydata, it appears that most of the care provided by veterinariansincluded administering antibiotics for respiratory and soft tissue

human competitors in the 2010 Iditarod Sled Dog Race, Am J Emerg

Fig. 3. Route of the Iditarod Trail Sled Dog Race.

4 J.W. Gallea et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

infections and performing wound care. These would likely becovered under Alaska's Good Samaritan law [8].

As illustrated by the single case of a medical evacuation thatwas required during the 2010 Iditarod, situations when musherssustain more significant and potentially life-threatening injuries orillness are much less common. There is no way to predict when orwhere such events might occur, but when they do, the race relies onits very well organized logistics system. At the center of this is therace's network of ski planes and snowmobiles, which is linked bysatellite telephones and pagers to each checkpoint and to the raceheadquarters. Checkpoints are staffed with local residents andveteran mushers who monitor the arrival and departure of teamsand preemptively initiate searches if a team is overdue. However, inmost cases, including the incident we describe, initial assistance isprovided by other mushers or some of the few spectators who arealong the trail (personal experience and knowledge of the firstauthor J.W.G., who has competed in this event). As illustrated by theemergency evacuation we report, there is excellent cooperationbetween these resources, allowing quick transport of a severelyinjured musher to definitive medical care. In other years, this systemhas served other mushers with various severe illnesses, hypother-

Please cite this article as: Gallea JW, et al, Injury and illness sustained byMed (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.018

mia, and carbon monoxide poisoning [9]. That there have been nohuman fatalities in the race's 41-year history speaks to the effec-tiveness of the existing system of care.

4.1. Limitations

Our study has several limitations that deserve consideration. Thiswas an observational study based on results of a survey and, con-sequently, is at risk for recall bias on the part of the respondents. Thefatigue and stress experienced by the mushers could well have in-creased the chances of forgotten or poorly reported illness or injury.Although we attempted to mitigate this by surveying mushers twiceduring the race, the likelihood of bias remains.

We did not attempt to standardize definitions or objectively verifyillness or injury. Mushers have varying degrees of race experienceand physical fitness. This likely influences their perception of theseverity of injuries or illnesses occurring during the event. The reportsof fatigue and dehydration are probably representative of this.

We only examined a single running of the race. Although a smallersample size is an obvious result of this limitation, the much largerand possibly less apparent problem with only sampling a single

human competitors in the 2010 Iditarod Sled Dog Race, Am J Emerg

5J.W. Gallea et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

year is that the weather and trail conditions are highly variable.During the 2010 Iditarod, the weather was very cold, reaching−46°Cat the halfway point while surveys were being conducted. How-ever, the snow conditions were generally very good and wind stormswere infrequent. In other years, temperatures rarely drop below −20°C, wind conditions can be challenging, or snow conditions arepoor, making the terrain difficult to navigate. Such variations in theweather patterns likely will impact the prevalence of various types ofinjury and illness.

5. Conclusion

Our investigation adds to the collective understanding of thefrequency and types of injuries and illnesses that can be predicted tooccur during extreme, cold weather endurance events. This type ofinformation will potentially allow participants to better prepare for,and possibly prevent, injury and illness during the competition. Raceorganizers and medical providers can use these observations to moreeffectively implement the type of medical supplies, services, andrescue resources that will be required to minimize risk.

Despite predictably harsh conditions, most injuries and illnessessustained by mushers in the Iditarod are minor and self-treatable. Life-

Please cite this article as: Gallea JW, et al, Injury and illness sustained byMed (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.018

threatening conditions are rare, and the need for a more organizedmedical care system seems low. Observations resulting from this surveymay be applicable to other outdoor extreme endurance sporting events.

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[5] Chapman RA, Tibbetts G, Case S, Evans DS, Mills WJ. Body composition testing ofathletes in the field using bioelectric impedance analysis. Alaska Med. 1992;34(2)87-90, 95.

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human competitors in the 2010 Iditarod Sled Dog Race, Am J Emerg