Coordinated Care at Major Events

By Darrin Scheid

For a while, athletic trainer Roy Flores, MS, ATC, LAT, said he felt a little like Andy Dufresne in “Shawshank Redemption.” Tim Robbins’ character wrote weekly letters to the government, requesting funds to improve the prison library. After years of trying, Dufresne got his way.

Flores took a similar approach, advocating year after year for athletic trainers to be recognized as their own category on the New York City Marathon medical volunteer team application. ATs were lumped in a subcategory under physical therapy. Flores would reluctantly check the box, complete the application, then send a letter requesting a separate category for athletic trainers.

Today, that category exists.

“I would just explain that we do different stuff,” said Flores, whose regular job is at Mount St. Michael Academy in the Bronx. “It’s a different set of skills. I guess it was three or four years ago that we got that changed. The New York Road Runners, NYRR, has been around for about 70 years, so it took a while. But we got there.”

It’s just a box on a form.

But for Flores and his athletic trainer colleagues, it represents something bigger, the visibility of the profession in some of the largest, most complex sporting events in the world. Whether it’s a 26.2-mile road race or a high-impact international rugby tournament, athletic trainers are there providing unique care.

Working a major event like the New York City Marathon isn’t just another day on the sideline. It’s a massive, coordinated medical operation.

Flores estimates that roughly 2,000 medical volunteers are spread across the race, from the starting line to the finish at Central Park. That includes physicians, physical therapists, athletic trainers, EMS personnel – even mental health providers.

At the finish line, the scene resembles what Flores calls a “mass unit.” Rows of cots fill a sprawling medical tent. Supplies are staged in bulk. As runners cross the line, they funnel into the tent in waves. Some are walking, other collapsing. Nearly all need some kind of medical attention.

“It’s organized chaos,” Flores said. “You might have three patients at once, all needing help at the same time.”

Whether at a medical tent along the course or at the finish line, for athletic trainers, that environment demands rapid triage, strong clinical instincts and constant adaptability. There’s no relationship with the patient like you would find in your collegiate or secondary school setting. Every interaction starts from zero.

While race day feels fast paced and reactive, the real work begins months earlier.

For athletic trainer Erica Marcano, MS, ATC, LAT, who helps coordinate medical coverage for large rugby events, including Rugby Sevens tournaments, logistics start four to six months out. Weekly planning calls bring together tournament organizers, medical directors and operations staff to map out every detail.

Her responsibilities include:

• Recruiting and assigning athletic trainers
• Coordinating physicians, residents and specialists
• Designing and updating the emergency action plan
• Determining medical tent layout and field coverage
• Planning communication protocols and transport routes

Unlike a controlled stadium environment, many rugby tournaments take place in public parks or shared venues, where resources and infrastructure are limited.

Marcano’s work with rugby started with her involvement with the Rugby Research and Injury Prevention Group. She started with them more than a decade ago as a data collector. The group recognized the need for injury data and asked Marcano to document injury as it relates to both mechanism and phase-of-play. This offers necessary insight into injury occurrence – and through that, risk mitigation – for rugby athletes in America.

She now serves as their head athletic trainer and performance specialist.

“There are always things outside your control,” said Marcano, founder of The Notorious ATC. “It’s about figuring out how to manage those constraints and still provide the best care possible.”

Injuries at large events differ significantly from traditional team settings. At the marathon, Flores said most cases are related to dehydration, muscle cramping, heat illness and general exhaustion.

“There aren’t a lot of acute orthopedic injuries,” Flores said. “It’s more the body breaking down after 26.2 miles.”

In contrast, Rugby Sevens rugby tournaments present a mix of acute trauma and ongoing issues. Marcano notes that wound care, including turf burns and lacerations, is common. Many of the matches switch between turf and grass surfaces. But one of the biggest challenges is managing chronic injuries.

“You might see someone who sprained their ankle six weeks ago, and you’re the first medical professional they’ve talked to,” she said. “It’s a balancing act because these athletes want to compete, sometimes in multiple matches in a single day. We provide guidance on how to manage pain and make return-to-play decisions.”

Flores recalls working alongside physicians and medical students early in his marathon experience. At one point, a resident physician asked him to evaluate a runner with hip pain, recognizing that orthopedic assessment is right up his alley. That moment reinforced what many ATs already know: Their ability to quickly assess, triage and manage musculoskeletal conditions is invaluable in high-volume settings.

But it’s not just clinical skill. It’s also communication, Flores said. ATs are often the ones who calm anxious participants, encourage exhausted runners, explain injuries in simple terms and build trust.

“You just give them that boost,” Flores said. “Sometimes it’s physical, sometimes it’s mental. Many of the participants are solo. You walk a bit with them, and you are the first person to ask how their race was. Their smile is its own reward.”

Why do athletic trainers keep signing up?

For Flores and Marcano, it’s the challenge and impact. Solving complex logistical problems, coordinating teams and adapting on the fly is what they trained for in school. There’s also the energy of the event itself. At the marathon, Flores interacts with runners from around the world, each with their own story. Some are chasing personal records. Others are completing a lifelong goal. Many are simply trying to finish.

Being part of that moment is powerful.

“You’re helping people at one of the biggest moments of their lives,” he said.

For Marcano, rugby offers a different kind of satisfaction – helping grow medical care standards in a sport that hasn’t always had consistent access to athletic training.

“It’s about making the experience better and safer for the athletes,” she said.