It is in human nature to constantly strive for tougher challenges, push further, to increasingly extreme environments. Any running race longer than a traditional marathon (26miles or 42.2km) is classified as an ultramarathon. There are over 5000 ultramarathon races every year worldwide. Many of these are located in remote and inaccessible locations, and some take place over multiple days. With the complexity, duration and rural location of these events, medical cover is required to reduce risks to participants. This falls under the remit of both wilderness and sports medicine.
The Highland Ultra Background
‘Beyond the Ultimate’ (BTU) hosts a 125 km ultramarathon in Knoydart, in the Scottish Highlands. The race is run over three days in particularly challenging terrain, with over 5500m of ascent.
The event is split into three stages. 54km, 42km and 29km. Basecamp, where runners sleep on the first and last nights, is located at Inverie, only accessible by ferry from Mallaig. At the end of the first and second stage runners camp at Kinloch Hourn. Aside from tents and drinking water provided at each camp, runners have to be self-reliant, and able to deal with any issues that arise on the trail. Clothes, sleeping bags, food and personal med kits must be carried by each runner.
Beyond the Ultimate specialises in arranging unique ultra-marathons across the world. The inaugural Highland Ultra took place in October 2021, and we attended during its second year. On this occasion, medical cover was provided by a team of 6 with a range of experience and backgrounds. This included a consultant team leader, three doctors, one physio, and one advanced nurse practitioner, however the composition of event teams can vary considerably.
Why Choose the Highland Ultramarathon as a Medic?
Working on the Highland Ultramarathon would be appealing to anyone who enjoys spending time in remote and beautiful places. There is no requirement to be any kind of runner; simply an appreciation of the Scottish highlands and a desire to combine professional skills and a passion for the outdoors.
Having worked for BTU in the past we understood its core ethos and values. They are a great team that take time to invest and support the local communities. For the Highland Ultra, event organisers source all food and beer locally from Inverie, plant one tree per entrant and reduce unnecessary waste by providing a water filter bottle to each runner. There is an expectation that volunteer medics are self-sufficient; it goes without saying that medics must be able to look after themselves first and foremost. Much of your personal equipment you have to provide yourself, including basic camping and hiking equipment and food.
Role of the Clinician
So what does working at this event actually look like? There is no clear answer to this – the joys of a pre-hospital environment come from a varied and unpredictable workload. It is common to find yourself in a very remote environment with limited kit and communications and as a result the planning stage is a vital part of the work. Establishing each member’s skillset, experience and areas of practice is essential in planning your medical response.
Each stage of this event presented its own challenges, and therefore each evening the medical team would liaise with the event coordinators to plan activities for the next day. This included highlighting challenging terrain, where specific risks would be encountered by runners and deciding where medical bags would be strategically placed along the route.
There were three types of kit bag: trauma bags, checkpoint bags and resus bags. Trauma bags were based at the start and finish of each day, being too cumbersome to be carried on foot across challenging terrain. Checkpoint bags accompanied a medic at each checkpoint. Resus bags could be carried more easily and were used in responding to emergencies. At basecamp, a wider range of kit was available.
Minor ailments can wait until the checkpoints or the base camp but anything more serious may require a swift action response. Due to dead zones in the phone signal we relied on trackers that identify runners’ locations and allow some basic messages to be sent. One potential emergency was encountered during the race and we received a message with no details at the time. We had to respond immediately to reach the runner, taking the resus bag. On arrival it was apparent it was a flare up of a pre-existing medical condition, and not in fact an emergency. The runner needed some supportive care and escorting off the route. No further intervention was required for this patient. However, this reinforced the necessity to be available and adapt to dynamically occurring incidents, sometimes with minimal information.
Working in any wilderness environment there always has to be consideration of the wildlife. Whilst there aren’t any exotic spiders in Scotland, there are ticks. Lots of ticks. The issue is that tick bites may lead to Lyme disease, with the iconic bulls-eye lesion (erythema migrans). Whilst ticks in themselves are not necessarily medical, the medical team has a role to play. The medical team can brief the runners about ticks, including some of the tips below. It is ultimately up to the runners to search for ticks themselves. We encouraged runners to correctly remove their own ticks where possible, some however felt uncomfortable and asked the medical team to assist. As a clinician some of the key points to remember are below.
- Always carry tick tweezers
- Check for ticks in places where the sun doesn’t shine
- Buddy up (might need this for tick 2)
- Long. Trousers. Always.
- Remind yourself about target lesions
Foot care and foot management was a common reason for presenting to the medics at the checkpoints and basecamps. Hot spots, blisters or toenails coming loose were experienced by most of the runners and had the potential to be race-ending issues if not managed appropriately. Having only had experience in secondary care, foot issues from running were not clinical presentations that we had come across previously.
Runners were encouraged to self manage their foot problems, given that they had the greatest experience with their own body. The medical team would only step in when they were unable to do so. There is little evidence available to guide foot care in long distance running; the only protective factor appears to be previous race experience1. Cumulative experience of these types of events is in itself preventative, which emphasises the importance of self-management.
The general guidance that we were advised to implement was three-fold; Prevention, Hot spots, Blisters.
- Participants were advised to bring their own blister prevention or management kit (such as tape) so that if they became aware of their own foot hot spots, they could manage it themselves before seeking medical attention.
- If a participant presented with a hot spot, defined as an area where friction is evident, but no separation of the skin layers has yet occurred (normally red and painful), advice about reducing friction was provided2. This included straightening out socks and/or the application of tape which would reduce further friction and hopefully prevent development to a blister.
- If the participant presented with a blister, advice was normally to avoid bursting/deroofing due to the risk of infection. If the blister was too big or too painful to allow the participant to continue, reducing the pressure by using a sterile needle and thorough cleaning was considered with close monitoring for infection. Thankfully very few blisters were encountered during the event that required this management.
For the future, and due to the lack of current research in the area, the medical team was keen to get a better idea on how to best advise and provide care to participants presenting with foot issues. Following this event, runners were asked to fill a research questionnaire to find out their experience of foot related issues and what steps they took to manage it, including self management as well as any intervention by the medical team. This research was carried out by a member of the BTU medical team with the intention of repeating the questionnaire after multiple BTU ultra events. This would provide a large patient sample size with demographics, variety of experience and interventions, to further understand what is the best method of preventing and managing these issues.
The Finish Line
Overall, the event progressed very smoothly, with nearly every runner crossing the finish line. For the medics there are long days with early starts and limited sleep. Unfortunately, one’s duty doesn’t quite end at the finish line. This is always the area where we needed to be the most vigilant. Runners’ mental resilience is put to the test as they fight to the end, but the pain they have been desperately trying to ignore may be a matter for concern. It is not uncommon to see runners fainting due to a mixture of sheer exhaustion, dehydration, low blood sugars, etc.
The icing on the cake is of course the well-earned rewards at the finish line. With the mood and spirits high it is very easy for medics to get caught up in the celebrations, but it is important to keep an eye out in case anything goes wrong. Luckily there were no complications, and everyone thoroughly enjoyed the evening with food and entertainment provided by the local community including pizzas and a folk band.
This event ticked all the boxes for us. It was great fun with a competent group of medical and non-medical staff. The weather was marvellous (very fortunately) as was the scenery. Beyond the Ultimate are a great organisation to work for. They are very supportive of the medical team, understand their limitations, and make the team feel valued by really incorporating the medics into the race team. They welcome medics to get involved with some of the wider race support during quieter times and foster a feeling of inclusion and teamwork. Any appropriately qualified individual with an interest in expedition medicine who wants to participate in exciting events within the U.K. should be reassured that there are many opportunities. The Highland Ultra is just one and we hope that this article and the pictures will inspire you to reach out and get involved.
For those new to expedition medicine, it is worth noting that most roles are on a voluntary basis. BTU provides a contribution to expenses, but it is always advisable to check what is and isn’t covered before signing up to these sorts of events.
Indemnity was free for both of us, but this is not always the case. As it was a voluntary role, with senior supervision, there was no issue in obtaining this from the MDU. It is worth arranging this well in advance of the event as the paperwork can take some time to be processed.
The main ways of hearing about these sorts of events are by word of mouth, by messaging companies directly, or by the adventure medic website. There are so many opportunities and events out there, the best thing you can do is express your interest early on and get involved in whatever you can.
The event occurred over three days (Thursday-Saturday), however, the BTU staff were already setting up the event a few days beforehand. The medical and runners were expected to arrive the prior (Wednesday) in good time to run though briefings and kit checks. We all left on Sunday. Some staff and runners did stay within the area to do some more exploring of Scotland, unfortunately, limited annual leave and primary job responsibilities meant that we had to return home.
Multiple methods of getting to the location were available. We opted to drive from Edinburgh due to time constraints. Our colleagues flew to Glasgow where we picked them up to drive to Mallaig. Some participants took the train to Mallaig (direct train from Glasgow) where the ferry left for Inverie (start location of the race).
It is likely that your travel costs will be covered by BTU. It is best to check prior to committing how much BTU will reimburse for travel. This is the same for their overseas events as well.
Other costs include:
- Any camping/hiking equipment that you may need (see list below)
- Your own food and snacks. Food and drink was provided on the final evening
- Any drinks at the local pub after the event
Kit and Equipment Not Provided by BTU
- Sleeping bag
- Sleeping mat
- Water bottles (ideally ability to hold at least 2 litres of water)
- Hiking trousers and shirts
- Socks and underwear (and spares. It is best to have as little cotton made clothing as possible due to difficulty drying wet clothing)
- Warm clothing (base layer, mid-layer, hat, gloves)
- Wet weather clothing (jacket and trousers)
- Food (ration packs/dry foods best, lots of snacks)
- Bowl + cutlery
- Head torch (and spare batteries)
- Notepad and pen
- Good pair of hiking boots
- Personal toiletries and sun cream
- Travel towel
- Dry bags
- Phone and power bank (+ cable)
- Blow up pillow
- Small stove (for having a brew at the checkpoints; hot water was provided at the campsites)
- Swimming trunks/swimsuits
This list is by no means exhaustive and it is purely for interest and to guide further reading.
Guidance for Medical Provision for Wilderness Medicine is useful for those with limited previous experience, and describes logistics, communications, and most crucially the level of support that should be provided, including capabilities of lead medics.
BMJ Best Practice: Heat Illness. The participants in these races are often extremely motivated and will push themselves to the limit when taking part. Heat illness is potentially life threatening and high risk at these events.
DermNet: tick bites and Lyme disease. These were very common and anyone coming away from the event without a tick bite (whether racing or support staff) were by far in the minority. Dealing with ticks and their potential consequences are important to understand.
Oxford Handbook of Expedition and Wilderness Medicine: A very handy guide to emergencies and treatments in the outdoor environment.
1.Scheer, B.V. et al. (2014) “The enemy of the feet,” Journal of the American Podiatric Medical Association, 104(5), pp. 473–478. Available at: https://doi.org/10.7547/0003-0538-104.5.473.
2.Dack, D. (2022) Hotspots while running – how to avoid hot feet when running -, Runner’s Blueprint. Available at: https://www.runnersblueprint.com/hotspots-running/ (Accessed: December 16, 2022).