The Polyclinic at the 1996 Atlanta Olympic Village

S Boyd Eaton, Blane A Woodfin, James L Askew, Blaise M Morrisey, Louis J Elsas, Jay L Shoop, Elizabeth A Martin and John D Cantwell

The Polyclinic, staffed mainly by volunteers, successfully provided primary health care during 16 519 patient encounters, 64% involving athletes. However, the profile of patient needs held some surprises.

MJA 1997; 167: 599-602  

Introduction - Planning, physical facilities and staff - Administration - Special services - Clinical services - Ancillary services - Further considerations - Use profile - Conclusions - Authors' details

	The best way to pay tribute to an illustrious past obviously lies in learning lessons from it to prepare for the future. Baron Pierre de Coubertin (instigator of the modern Olympic Games and first President of the International Olympic Committee)
Introduction	This report describes the challenges and experiences of operating the Olympic Village Polyclinic, the health centre for athletes and staff during 33 days of preparation for and competition in the 1996 Olympic Games. In Coubertin's spirit, we hope the analysis will be useful to medical care planners for future events, including the Sydney Olympic Games in 2000.
Planning, physical facilities and staff	The Polyclinic's mission was to care for athletes (3100 women and 7750 men) and Olympic "family" (4500 administrators, coaches, officials, physicians and trainers) living in the Olympic Village. Other personnel (4000 volunteers, 3600 contracted service employees and 1800 security forces) were also given emergency and, when expedient, routine services. The planning committee had 25 members, comprising administrators, trainers, dentists, nurses, optometrists, podiatrists and physicians, and began work in 1992. Several members had been observers at the Barcelona Olympic Games (1992) and the Lillehammer Winter Games (1994) and operated a small polyclinic during the 1994 Goodwill Games in St Petersburg. The Polyclinic was established in the Student Health Center of the Georgia Institute of Technology, under a contract between the Atlanta Committee for the Olympic Games (ACOG) and the Institute. The Health Center is a two-storey building with a floorspace of about 2300m2 renovated in 1994-1996. Personnel from the Health Center formed the nucleus of the clerical and administrative staff, while shifts of volunteers helped meet the demands of 24-hour operation. Overall, 18% of staff were employed (39% of clerical and administrative staff) and 82% were volunteers. The physical facilities and staff of the Polyclinic are shown along with patient numbers in Box 1.
Administration	Patient reception and medical record storage were adjacent, and cross-trained staff could work in either area. Incoming telephone and facsimile lines were also housed there, but use greatly exceeded expectations and hampered other operations. The admitting area was often congested by non-patients. Patient registration and other paperwork were handled manually, as computerised filing was unavailable. The process would have been improved by optical scanning of bar-coded accreditation, automated generation of encounter forms and computerised generation of epidemiological data.
Special services	Sports medicine: Physical and massage therapy and athletic training were housed in a separate facility about 750 m from the Polyclinic and handled by athletic trainers and physical therapists supervised by the Village Medical Director. Patients could be referred by team or Polyclinic physicians or could self-refer. In the latter case, they were assessed by an athletic trainer or physical therapist, and any whose condition was in doubt were sent to the Polyclinic for evaluation. There were about 2000 visits for massage therapy and 3000 for physical therapy with, to our knowledge, no inappropriate treatment. Doping control: Two rooms were maintained so athletes unable to void after evening competition could be observed in a central location; these were used nearly every day. Gender verification: This program, mandated by the International Olympic Committee (IOC), was segregated from the rest of the Polyclinic, with a separate entrance so that large numbers of athletes could be processed without congesting clinical areas. All women athletes participated, except those competing in equestrian events (which are mixed-sex) and those who had been gender-certified at previous Olympic competitions. Height and weight were recorded, a photo-identification card was made, and a series of buccal smears were obtained for DNA extraction; the process required about 10 minutes. About two-thirds of gender testing was done over the six days around Opening Ceremonies, when the unit operated from 0800 to 2200. It processed 837 athletes on the peak day. Specimens, identified by number, were sent by bonded courier to the Emory University Genetics Laboratory, in Atlanta, for analysis. A few participants were found to have SRY DNA (generally about one woman in 500 has a Y chromosome) and were further evaluated by a medical geneticist and a female gynaecologist, with prompt, confidential examinations to avoid stigmatisation. No men masquerading as women were encountered, and all participants were cleared for competition. However, in future Games, it may be more efficient for gender verification to be housed at the Accreditation Center rather than at a medical facility.
Clinical services	Dentistry: A team of volunteer dentists (including an oral surgeon), dental assistants and hygienists served about 910 patients, taking over 500 dental radiographs and performing about 400 fillings (290 amalgam, 110 composite), 84 extractions, 62 endodontal procedures and 14 oral surgical operations. Eye services: Each shift included two optometrists, an ophthalmologist and an optician. The 790 patients were provided with 620 pairs of spectacles and 50 sets of contact lenses. Beyond vision correction, clinical problems included corneal abrasions, conjunctivitis, pterygium, pingueculitis, glaucoma and blepharitis. Three chalazion excisions and one repair of a post-traumatic cicatricial ectropion were performed. Primary care: Patients with general medical complaints were treated by internists (primary care physicians) and family practitioners, assisted by registered nurses. Sprains and strains were the most common conditions (Box 2); those involving athletes were referred to orthopaedic surgeons. Exotic infectious disease was less common than anticipated, with eight cases of malaria (seven had been previously diagnosed), three of hepatitis and one of filariasis. Nine patients requested HIV tests, yielding no positive results. An unexpected amount of time was required for telephone consultation with National Olympic Committee team physicians, most of whom requested notification before their country's participants were evaluated or treated. Establishing these contacts was often difficult. Another time-consuming activity involved patients initially sent to primary care but ultimately referred to specialty care. A triage physician stationed in the admitting area would have improved patient flow. Orthopaedics: 222 patients (70% of them athletes) were treated. Knee injuries were especially common (about 70), equalling in frequency the next three most numerous injuries (hand/wrist, ankle, and shoulder). Orthopaedic supports, especially knee braces, were in short supply; a larger stock (starting each day with 6-8 in each size) would have been desirable. Twelve arthroscopic procedures, chiefly meniscectomies and cruciate ligament reconstructions, were performed off site by Polyclinic orthopaedic surgeons during the Games. Other specialty care: Unexpectedly few gynaecology patients (25) were treated, despite a record number of women athletes and staff. A contributing factor may have been the presence of some male gynaecologists; several patients refused services on learning the physician on duty was a man. One athlete was unexpectedly found to be pregnant. Similarly, surprisingly few patients availed themselves of the psychiatry/sports psychology service, and no visits were related to the Centennial Park bomb explosion. However, the encounters that occurred emphasised the service's importance. One athlete became overwhelmed by the prospect of Olympic competition, deciding to return home prematurely, but after psychological intervention successfully advanced to the quarter-finals. In another case, emergency treatment was needed for an acute psychotic breakdown. Podiatrists saw over 200 patients and dispensed modified orthotic devices for 65. Dermatologists treated 112 patients, while nearly 240 additional patients with skin disorders were treated by primary care physicians. Otolaryngologists saw 110 patients; two rooms were originally designated for otolaryngology, but one was sufficient, and the other was used for eye services. Emergency medicine: 24-hour emergency care was provided. Each shift comprised one emergency physician and two ambulance-based paramedics, with two registered nurses during the day, but only one at night. A night-time clerical support person would have been very helpful. Patient numbers ranged from 4 to 22 (night) to 3 to 9 (day). Chest pain, lacerations, abdominal pain, multisystem trauma, head injuries, and seizures were common presenting complaints. Heat-related conditions, often problems at outdoor events, were uncommon (29 cases). Communication with National Olympic Committee team physicians, competition venues, referral hospitals, the medical command centre, and especially with ambulance crews, was a vital emergency physician function. About 125 patients were transported from the Village to one of two nearby Olympic-affiliated hospitals. Of these, about a third were dispatched directly from the pick-up point, while the rest were first evaluated at the Polyclinic. About 70% of patients sent to area hospitals were discharged after evaluation.
Ancillary services	Pharmacy: Pharmacists were present 18 hours per day; emergency call-back was available but unnecessary, as drugs in the emergency room were adequate for night-time needs. All drugs in the IOC-approved drug formulary were stocked, while restricted and prohibited drugs were stored separately and flagged in the pharmacy computer to prevent inappropriate dispensing. Just over 3600 prescriptions were filled, with a one-day high of 219. Ibuprofen, amoxycillin, naproxen, acetaminophen, cimetidine, clotrimazole, diazepam, terfenadine, guaiphenesin/dextromethorphan and phenol/menthol lozenges were most commonly dispensed, but 282 different preparations were ordered at least once. Clinical laboratory services: Laboratory services were available from 0700 to 2300 during the first 10 days and around the clock thereafter, requiring 10 technicians to work overlapping shifts. About 500 patients were referred for 937 tests, including complete blood counts (213), biochemical profiles (129), urinalyses (114), group A streptococcal screens (42), and erythrocyte sedimentation rates (33). A fifth of all ordered tests were performed at a nearby laboratory (e.g., stool sample culture/sensitivity or "ova/parasites", thyroid profiles and microscopy of malaria smears). Imaging services: In preparation for the Games, the Health Center's radiography room was updated to allow digital acquisition and processing of radiographs. Sponsoring manufacturers provided ultrasound equipment and a mobile magnetic resonance imaging (MRI) unit (placed in a nearby car park). Teleradiography links were established with two Atlanta hospitals. Imaging included 744 radiography examinations on 634 patients (about 60% athletes), with 50 examinations on the peak day; 204 MRI studies (mostly musculoskeletal); and 112 ultrasound studies (about half musculoskeletal).
Further considerations	Language services were provided by translators, generally via "speaker" telephones; 31 languages were available and service was always provided within 45 seconds. Although translators were not specially trained in medical terminology, it was always possible to obtain adequate histories and other necessary clinical data. As the security cordon around the Village complicated resupply, an individual was assigned logistical responsibility. He became familiar with the elaborate (and frequently changing) protocols for moving supplies and equipment into the Village after "lock-down", and developed a good relationship with logistics and security officials. Thus incorporated into the system, the Polyclinic was able to procure necessary matŽriel despite the burdensome bureaucracy, even when unanticipated needs arose. The possibility of terrorism was considered during planning. Polyclinic personnel received instruction on bomb blast injuries and care of chemical/biological warfare victims. The pharmacy stocked pralidoxime chloride and atropine for treating nerve gas poisoning. A facility was prepared for hosing down individuals contaminated with gas or radio activity. Atlanta's chiropractic community offered to provide services in the Village. This proposal was referred to the IOC Medical Commission, which, in keeping with previous Olympic practice, ruled against accepting the offer.
Use profile	Use of the Polyclinic followed the Seoul/Barcelona pattern: operations began 13 days before Opening Ceremonies and extended for three days after Closing Ceremonies. The slow first week was invaluable; equipment was tested, personnel became familiar with the system, supply deficiencies were corrected and unexpected problems were addressed. Thereafter, volume increased to a plateau extending from before Opening Ceremonies to the end of the first week's competition. Use gradually declined until Closing Ceremonies, and then fell rapidly. Demand for MRI and ultrasound imaging increased steadily.
Conclusions	Most Polyclinic staff were volunteers, who provided commitment and enthusiasm, as well as expertise. However, most were unable to serve throughout the Games, which meant personnel varied from day to day, introducing confusion and inefficiency during the early stages and hindering effective communication. However, although using fully contracted staff may have avoided these problems, we believe the esprit de corps provided by volunteers far outweighed the inconveniences. Interaction with public health officers was more important than originally anticipated, requiring near-daily communication between Polyclinic physicians and the public health team, chiefly about potentially communicable diseases. Athletes, and especially Olympic "family", could be regarded as taking advantage of the opportunity to obtain free eyeglasses and dental fillings. Perhaps providing these has become an unstated obligation of the host city; clarification with the IOC Medical Commission is probably in order. No amount of preparation can anticipate all contingencies, so a flexible outlook is essential. While the 1996 Polyclinic usually adjusted appropriately, triage was a failure. The need for a physician to direct patient flow became apparent immediately, but schedules could not be revised to allow this. In contrast, the eyecare team was able to successfully reorganise procedures for spectacle delivery when it became apparent that the original plan was inadequate. While aspects of its organisation and function could have been improved, the Polyclinic achieved its most important objective - providing medical services during 16 519 overall encounters, 10 641 (64%) of which involved athletes. With respect for the sentiments of Baron de Coubertin, and in the Olympic spirit, we hope this report will help health care personnel charged with like responsibilities in the future to approach the optimum more closely. (Received 25 Mar, accepted 26 Sep, 1997)

Authors' details