Medical incidents at mass gatherings and events can be separated into primary care, emergency care, and major incident.9 The medical components should include accessible primary care stations inside the event, response elements embedded within, and transportation staged in a well thought-out location nearby. Gatherings also provide vulnerability to participants by the simple nature of a crowd effect, density, relative anonymity of would-be criminals and have recently served as targets for terrorists10 (Atlanta Olympics, Boston Marathon). This increasing threat of targeted, large-scale violence at mass gatherings requires even more preventative foresight and catastrophe preparation.
Provision of medical care at a mass gathering event can be complex as it integrates multiple aspects of medicine including public health, primary care, and emergency medical services. Management of any medical incident at an event requires coordination with the other logistical elements intrinsic to the event itself including security, event coordinators and staff, and the participants or public.11 In addition, Arbon describes three elements that affect the health of participants including environmental factors, the psychosocial component of the crowd, and the biomedical aspect which includes the overall baseline health of participants and may include widespread involvement of drugs or alcohol.12
The most common types of mass gatherings are sporting events, concerts, and various festivals, fairs, and religious gatherings. Sporting events most often cited in the literature include the Olympic Games and those played at the collegiate or professional level.13-21 Many of these are held in fixed stadiums with nonmoving crowds and difficult access to care. Other athletic events such as triathlons, endurance races, and other long distance events are more spread out, requiring medical assets to be staged throughout the course.22
Similar to stadium-based sports, concerts generally have fixed and nonmobile crowds unless multiple stages exist. Rock concerts in particular have been associated with higher patient presentation rates due to drugs, alcohol, and mosh pits.23-26 Fairs and festivals, on the other hand, are generally spread out with a large number of participants over multiple days and therefore pose their own unique problems in regard to planning and staffing.27-32
Most patient complaints can be categorized as either traumatic, medical, or support. As mentioned previously, certain events (ie, rock concerts) are more likely to produce specific types of patient complaints (ie, orthopedic injuries). Several mass gatherings have been described in the literature, documenting specifically the rates of patient presentations and chief complaints. A retrospective review of the New York State fair over a 5-year period showed an average patient presentation rate (PPR) of 4.8/10,000. The three most common complaints were dehydration (11.4%), abrasions/lacerations (10.6%), and falls (10.2%) (Table 68-1).30
Top 3 Complaints at the New York State Fair (2004-2008)
|Favorite Table|Download (.pdf) TABLE 68-1
Top 3 Complaints at the New York State Fair (2004-2008)
|Dehydration ||11.4% |
|Abrasions/lacerations ||10.6% |
|Falls ||10.2% |
Other events, such as concerts, would be expected to have more traumatic injuries. A review of 405 major concerts in the 1990s showed that rock concerts had approximately 2.5 times more patients than nonrock concerts.24 However, the distribution between traumatic injuries and medical complaints were the same. Other events that produce traumatic injuries include outdoor races, demonstrations, and rallies, events that include active participation such as climbing or fighting, and events that utilize dangerous elements such as pyrotechnics.8,27
There are many characteristics that can be used to predict the types of injuries to expect. In a 2002 review of the literature, Milsten et al identified the most common variables affecting injury rates and injury types which included venue size and participant numbers, among others (Box 68-1).8 Duration of the event, venue type, and location are also major variables in predicting patient load. Events held indoors vary based on spectator mobility.
Box 68-1 Most Common Variables Affecting Injury Rate/Type
Crowd mood and density
A study reviewing injuries at an Olympic venue showed higher rates for mobile crowds vs seated crowds.8,13 Indoor events should be evaluated for points of egress and other barriers. Venues held outside have many contributing factors. Environmental exposure to excesses of heat and cold are major contributors to health problems at mass events.7,8,12 Preparations for exposure should be taken seriously. Leonard points out the following common-sense fact: whatever is in or around the venue that can produce injury should be expected to produce injury (ie, if there is water, anticipate drownings; if there is elevation, consider falls; if proximity to insects or animals, expect bites, etc).5,8
Certain crowd demographics can also predict injury patterns and rates and should be considered when planning. The age of the population—older crowds are generally more frail and have preexisting health problems. The mood of the crowd- the density of the participants, and the consumption of drugs and/or alcohol have been shown to affect injury patterns and rates, as mentioned previously.5,8,12
Two additional vulnerabilities of mass gatherings merit special preparation. Congregations of people are vulnerable to public health risks including exposure to contagious pathogens via respiratory transmission, food preparation and distribution, contaminated water sources, and inadequate sewage management.14 Khan describes the preparations made to treat a feared influenza epidemic during the Hajj pilgrimage and represents an example of promoting public health stewardship during a temporary mass event.31 Terrorist plots frequently target groups of people to maximize injury. Recent domestic examples include the Atlanta Olympic bombing and the Boston Marathon bombing. Coordination among event planners and responders should take these risks into consideration and allocate appropriate contingencies for mass casualties.10,33
In 1990, the American College of Emergency Physicians (ACEP) developed a step-by-step guide for providers to aid in the preparation of the medical component of mass gatherings.5 A decade later the National Association of Emergency Medical Services Physicians (NAEMSP) published Mass Gathering Medical Care: The Medical Director's Checklist.7 Foresight and preparation are paramount to providing safe and an effective medical delivery and developing a medical action plan will streamline the process.
The medical action plan is an essential organizational tool for the preparation of medical delivery at mass gathering events. The plan should be used in all stages of organization and in the execution of medical care. It will require the approval of the medical director and must strictly follow all applicable laws and protocols. Fifteen components comprise the medical action plan (Box 68-2).
Box 68-2 Components of a Medical Action Plan
Physician medical oversight
Negotiations for event medical services
Level of care
Public health elements
Access to care
Emergency medical operations
Command and control
Continuous quality improvement
Medical oversight should be provided by a physician capable of caring for the acutely ill patient, preferably have EMS training or experience. The medical director assumes the mantle of responsibility for all medical operations during the event and thus must understand the applicable laws pertaining to medical administration, interpret the medicolegal implications, and participate in the assessment of risk. An agreement in the form of a contract should be drafted for the medical component and the event leadership that contains such details clearly spelled out. The medical director should determine the appropriate level of care, and be available for consultation to assess staffing needs, estimate medical supply volumes, and develop the formulary. The contract should contain other important details including deadlines and negotiated terms such as payment and liability agreements.6,34
The planning stages for the event should commence months or weeks prior to an event depending on the size, scale, and complexity of the event. Events that are complicated by large-scale, heightened security concerns, and complex venues or event design may require a year or more to plan. In the early stages, reconnaissance of the venue site and medical resources should be conducted. The venue should be inspected to identify potential risks and sources of injury. The information gathered from the site will guide planning strategies regarding intraevent transport and communications, to determine location options for command structure, treatment, and mobile staging sites, as well as to plan emergency egress, mass casualty related points and establish landing zones or other transport hubs. Medical reconnaissance should help identify medical resources and staff onsite or that is otherwise provided, estimate needed medical supplies and volumes, serve to introduce leadership of participating parties if applicable, and establish an interface with local EMS systems.8
The medical director should meet with event organizers prior to the event to discuss the medical plan and ensure buy-in by those involved. Topics of discussion include equipment/supplies, staffing, communication equipment, potential compensation, and medicolegal issues such as liability coverage.
As indicated earlier, a fundamental part the medical action plan is determining the level care appropriate for the event. Several studies show that events tend to consist primarily of “well” people and that the majority of injuries are low acuity.1,8,15,27 However, acute emergencies may arise anytime which makes it essential for the responders to assess, stabilize, and treat or transfer. A venue's interface with existing EMS systems may dictate how autonomous the medical operation should plan to be. An early paper describing medical provisions at the Winter Games in Calgary showed that ALS level providers were not needed in the urban areas because of the proximity and accessibility of the city EMS system; however, ALS level providers were essential in the rural areas.15 ALS and physician level care may be required in austere locations where transport time is unreasonably long.27 The medical director should exercise discretion in selecting the level of care based on resource availability and other contributing factors and should match the standard of EMS care available in the surrounding area.
Medical equipment, supplies, and formularies should be thoughtfully planned in advance. Although some literature describes the need of specific items such as cardiac defibrillators,35,36 resources are generally scarce overall. There are numerous generic event medical supply lists in textbooks and in other medical literature which may help. These lists can serve as a starting point and be tailored to a specific event. Preparatory steps start with reviewing the treatment level, protocols, and expense allowance. Anticipating the expected needs and volumes of the event is a notoriously difficult aspect of planning. Practical supplies such as paper, pens, and folders should be considered in the inventory as well as personal comfort items such as sunscreen and insect repellant.34
Some events will require modest medical facilities consisting of mobile providers working out of a medical bag or an ambulance. Large venues and prolonged events will likely require a specified, onsite treatment location such as a tent or room that can serve as the triage and treatment site. An onsite treatment facility must be clearly marked, and its location widely known to the providers, event staff, and participants. The on-site location should maximize accessibility for providers and patients, and provide maximal proximity to off-site transport.
Communications is the most vulnerable part of the medical action plan and therefore proper planning is important. EMS personnel at mass gathering events typically rely on the radio capabilities of local EMS agencies (eg, UHF vs digital) and therefore extra radios and batteries should be available. Staff should be trained on radio operations and the use of clear speech. Phone service (land line, cell, satellite) can serve as a backup to radio transmission or serve as the primary means of communication . Text messaging in particular can be useful when high ambient noise renders audio transmission unreliable.37
Medical Command and Control
The organizational structure of medical provision should integrate with the larger administrative command system and clearly outline authority and responsibility. Some authors encourage using the unified command model, particularly if multiple EMS and/or law enforcement agencies are involved.34 The medical command center should be accessible and clearly marked. The location could be either on- or off-site depending on the layout of the event site, but for reasons of convenience, it is ideal to be adjacent to other organization centers (security). The center should have at least one person present at all times.
The advantages for onsite medical control are well described. Having a physician onsite is beneficial for the safe release of patients back into the crowd.38 Onsite physicians also reduce the number of off-site transports and decrease the patient burden on the local EMS systems.29,38 Physicians are usually responsible for developing protocols at events and if on-site are able to reexamine or modify treatments as needed.39 Finally, physicians have the expertise and the authority to render definitive medical decisions and appropriate refusals of care.34,39
Prior to an event the medical director should establish the method for documenting patient interactions. Often the local EMS patient care report (PCR) is used but, if an event is large enough, a customized form may be more desirable. At a minimum the PCR should include the following: patient's name, contact information, chief complaint, impression, treatment, and disposition.
All records should be kept on file for at least as long as mandated by state law. For minors of some states, this may mean the clock does not start until the age of maturity. Immediately after an event, the medical director or their designee should conduct an organized audit of patient care. In the case of emergencies or mass casualty incidents where a PCR may not be available, whatever information is at hand (triage tags) should be used. Review of these records allows for changes and recommendations for future events.