Forty mph winds pelted cold rain against the runners as they approached the Boston Marathon’s infamous Heartbreak Hill. It was just before this mark that runner Courtney Duckworth’s eyesight started to blur. She couldn’t tell if her senses were warped from the terrible weather conditions or if it was something more serious. Living with Type 1 diabetes, she is used to keeping track of her health while she runs. 
 
Due to the treacherous conditions she knew this race wasn’t going to break her personal record, so she popped into a Gatorade tent to check her blood glucose level. Her fingers were numb from the frigid conditions. When she pulled out her traditional blood glucose monitoring kit she needed help from volunteers in the tent. She began instructing them how to use the meter, but that’s when things went south. 
 
“They were trying to balance my meter on top of the Gatorade jug and someone accidentally pushed it into a cup of Gatorade. And the guy started freaking out and I’m freaking out on the inside,” Duckworth told MobiHealthNews. “I tried to calm him down and say 'it’s OK, it’s OK,' but on the inside I’m like ‘oh my god I can’t believe that actually happened.’ And then the meter wasn’t working and it’s still not working after that. It definitely died.”
 
Luckily, this wasn’t Duckworth’s only method of checking her glucose level. This was her first marathon using a continuous glucose monitor, commonly referred to as an “artificial pancreas,” which continuously check blood glucose levels 24-7. Her CGM, the FreeStyle Libre by Abbott, which sponsors the World Marathon Majors, is made up of a sensor and a reader. While she is on the go she can scan her reader over the sensor, which is continuously monitoring her blood glucose, in order to easily see her glucose level. 
 
“My Libre was the only thing I had to base my treatment decisions on so I swiped my Libre,” Duckworth said. “My [glucose] number was slightly higher than what I wanted so I knew at least it wasn’t low. So I adjusted my insulin and was able to use the glucose that I was putting into it more effectively.”
 
Duckworth isn’t the only runner using digital health technology this marathon season. Marathons are on the brain this week as runners look back at the Boston Marathon, which took place on Monday, and look ahead to the London Marathon, set for this Sunday. The events require an enormous amount of training from athletes and coordination from organizers. Today both are turning to technology:  many athletes are using wearables to keep track of their training, and coordinators are looking to connected medical devices to provide care on the spot. 
 
Some of the newest medical technology can be seen at the oldest continuous marathon, the Boston Marathon. On Monday 26,948 runners entered the race. By the end of the day, 2,795 of those runners had sought out medical treatment from one of the medical units provided by the event, an event organizer told MobiHealthNews

Coordinating medical help on the course

The Boston Marathon has an elaborate medical operation made up of 26 medical stations set up along the course, and four medical facilities after the finish line for runners post race. There are 1,800 medical volunteers who keep the facility going. 
 
Connected technology is key in tracking runners as they check in and out of these stations. For example, on the day of the race every runner wears a bib with a barcode attached. When a runner needs medical attention their bib gets scanned. Their name and contact information is fed into an online platform. 
 
“I’m able to look at a dashboard on a computer and have all these data points,” Boston Marathon Medical Coordinator Chris Troyanos told MobiHealthNews. “It allows me to have real-time awareness and gives me an idea of what we need to do and how we need to respond.”
 
The program, called EMTrack, is provided to the organizers by Boston Emergency Medical Services and keeps track of all the runners. It shows which medical tent a runner has been checked into and if an athlete has been admitted to one of the area hospitals. This year the program tracked 97 runners who were taken to hospitals. It continued to track the 10 that were admitted for further treatment. Troyanos and his team of volunteers, who he said he couldn’t do this job without, made sure injured runners get to where they need to be. 
 
However, when a major crisis takes place like the Boston Marathon Bombing of 2013, which left five dead and 264 injured, normal tracking isn’t the top priority. 
 
“The thing about the events of 2013, [was] basically a lot of things ceased when you get into a situation as tragic as that,” Troyanos said. “Normal systems go out the window. You are responding to what is in front of you and the tragedy and types of people that need to be cared for, so tracking at that time didn’t make any difference because the people we were bringing in were spectators. Our goal then was to do immediate care for those people. Tracking was a secondary situation.”
 
But the organization has been integrating new technology that could help in a similar crisis. Recently Troyanos and his team implemented an emergency text messaging system through Everbridge. This gives Troyanos and other organizers the ability to send out messages to everyone on the medical team or a select subgroup. 
 
“Say, for instance, in 2013 where we had to institute a course disruption plan and stop people from coming into Boston. We can do that at a much quicker rate than we were able to before,” Troyanos said. 
 
But the texting system isn’t just for emergency situations, as it can be helpful for coordinating care for patients as well. It’s not uncommon for one of the tents at the finish line to get full. In this situation, one of the officials could communicate and send patients to a tent with room. 

Treating the runners with digital health inside the tent

There is a set of protocols for when a patient is checked into the medical tent. For example, before any patient gets an IV the medical staff checks their blood sodium levels. In five out of the six major world marathons (all but Tokyo), the medical team checks blood with the i-STAT, a wireless point-of-care blood analyzer.
 
The device uses a disposable test cartridge to perform the blood tests where it can look for cardiac markers, blood gases, chemistries/electrolytes, coagulation, and hematology. It takes a few minutes to test the blood, which means that clinicians don’t have to send the blood the lab. 
 
“This is used anywhere a blood result is required quickly,” Narendra Soman, director of instrument engineering R&D at Abbott, and i-STAT developer, told MobiHealthNews. 

The device is typically used in in operating rooms, outpatient clinics, or anywhere else that blood test results are needed quickly, as well as in remote areas where there is minimal access to labs, according to Soman. Because runners are treated on the spot, it makes sense for the i-STAT to be used at marathons. 
 
Sometimes getting the proper care to a patient isn’t the only hurdle. This year runners from 106 countries participated in the Boston Marathon — speaking dozens of different languages. Not every runner was able to explain their symptoms or needs in English. That’s where a technology called Language Access Network came in handy. 
 
“It is an international event and [we] have a number of runners who speak various languages. When they come in the medical tent, how are we going to be able to determine their needs?” Troyanos said. “So we partner with Language Access Network and we have their staff in the tents with tablets and we are able to connect with their network of translators. It’s kind of like a FaceTime approach [where we] can talk to a third person to determine what [the runner] needs.”
 
Meanwhile, others like Duckworth are keeping track of their own health through monitoring systems like a CGM. Duckworth and her fellow runner Patrick O’Brien used the Freestyle Libre system for the first time this marathon after Abbott offered them the opportunity to try out the technology for free and helped facilitate their participation in the race. 
 
Before this the runners used traditional meters, which meant they had to stick their fingers during races. This could slow racers down and be a distraction, Duckworth said, whereas latest technology allowed the runners to scan their sensor while competing for a quick glucose reading. 
 
“I [started] using the FreeStyle in the training about two and a half, three months ago,” O’Brien told MobiHealthNews. “It is great compared to the traditional glucometers, which [are] time consuming, [and] not ideal especially when you are out running and don’t especially want to stop.”
 

Runners look to wearables for pre-race training

But before runners even get out on that course they must do enormous amount of preparation. Many runners are turning to wearables to help them train. 
 
Sandra Kaulfuss, a runner who will be competing in the London Marathon on Sunday, uses her Garmin to track distance, pace, and heart rate. 
 
“I ran three half marathons without it and it was very different because I didn’t know what my pace was like or my effort was like,” Kaulfuss told MobiHealthNews. 
 
It might feel like she was pushing herself, she said, but without the heart rate data she didn’t have a clear picture. The heart rate data from the fitness wearable lets her know when she can push herself harder. 
 
Runner Scott Goldstein, who just completed his second Boston Marathon, said his Garmin keeps him motivated to run.  
 
“Over the years you collect a lot of data because I’m wearing this 24-7 and have some cool graphs and interfaces,” Goldstein told MobiHealthNews. “They are constantly coming out with new ways to train better and smarter.” 
 
Major tech companies have integrated long distance runners’ needs into their technology, Scott McLean, principal scientist in Exercise and Activity at Fitbit, told MobiHealthNews. 
“We have a couple of features that are really geared towards distance runners, the most prominent one is our Cardio Fitness Level,” he said.
 
Fitbit’s Cardio Fitness Level gives users a score of one to 100, with 100 being the maximum fitness level. This correlates with a Vo2 Max score, a measurement of oxygen available to the body during intense exercise. But McLean said that it is easier to get this score than a typical Vo2 Max score, which is generally determined using a test that costs between $200 and $300 and requires runners to do an exhaustion test. In order to get a fitness score, users only need to go for a run. 
 
McLean also noted that many runners find the heart rate monitor very useful when training. Several of the major brands including Fitbit, Apple, and Garmin have products that include a heart rate monitoring feature. 
 
More complex training systems aren’t for everyone; for some runners with chronic conditions, making their life a little easier and their race a little simpler is what matters the most. 
 
“I never got that fancy. I tracked my mileage and my pace but never heart rate or anything like that,” Duckworth said. “You can only juggle so many metrics in your head, and worrying about my blood sugar was enough for me.”