With increased participation in venue medical care, there has been an increase in the literature focusing on medical care at mass gatherings for both spectators and athletes.23-36 Venue medical care, especially for the spectators, has generally been the domain of nonphysician personnel. In the past, most venues have been covered in agreements or private contracts with the owner of the venue or the government agency managing the venue. These contracts have often been awarded based on politics (connections, relationships with stadium owners, managers, or management decision makers) rather than on the level of expertise. Yet, increasing liability has increased the need for physician input and coverage.
Based on their level of training, experience, and clinical expertise, the emergency physician is the obvious choice for organizing and supervising medical care at venues for mass gatherings including athletic events, music concerts, and even large sales conventions.
There are many factors to consider when evaluating a venue to determine the level of care needed and the staffing numbers. These factors include indoor versus outdoor, seated versus nonseated, environmental conditions,37 event site, attendance, attendees, particular type of event, and the availability of food, water, alcohol, and drugs (Table 52-3).
Table 52-3 Factors Affecting Usage of Venue Medical Services |Favorite Table|Download (.pdf)
Table 52-3 Factors Affecting Usage of Venue Medical Services
Age (no alcohol)
To address a specific venue's needs requires the sports medicine physician provider to develop a plan with staffing and programs that are adapted to the specific venue or stadium to be covered. Stadiums are not designed for medical care. It would be ideal if the medical provider could assist the architect to ensure an emphasis on safety issues, adequate space for medical response, and location and design of medical stations. However, generally medical care stations are an afterthought and providers are left to utilize available space and forced to design a response with the predetermined architectural constraints of the venue.
There are no specific training programs for venue medicine, although the principles of emergency medicine, EMS fellowships, and disaster medicine address important components. Venue medicine has typically been the domain of the EMS community or a nonemergency physician with little knowledge or desire to participate in spectator medical care.
The range of venue types are numerous and may include indoor stadiums, outdoor stadiums, outdoor concert seating arrangements, sporting events, rock concerts, conventions, and a wide variety of events that may attract crowds ranging from a few hundred to greater than 100,000 people. There is some literature regarding the incidence of injuries and summaries of medical care at mass gatherings.
There is little specific literature on the level of training required for personnel. Fortunately, the emergency physician does not need specific training except knowledge of the venue and a desire to participate in the care of the injured or ill spectator. The on-site preparation for the emergency physician consists of evaluating all areas of the venue in an effort to become familiar with the multitude of variables unique to the venue that will affect the medical response. After this is completed, a comprehensive plan specific to that particular venue can be developed. The full spectrum of illness and injury seen in the ED may be encountered in the venue. Therefore, it is necessary to make appropriate preparations to address the probably level of care to be rendered.
Organization Specific to a Venue
The specifics of the plan depend on the type of venue and scope of treatment services. During the organizational phase, it is appropriate to utilize some general guidelines. But the specific plan, including the medical team coordination, must be tailored to fit the specific venue with an accurate working knowledge of its individual nuances. It may be necessary to downsize or upgrade staff based upon the changing crowd expectations or conditions at the venue.
General guidelines and recommendation may suggest the number of physicians, nurses, and paramedics and/or emergency medical technicians (EMTs) that may be utilized at sporting events, but the specifics of the individual venue must guide the actual deployment. For example, the unwritten “rule of verticality” increases staffing needs because of multiple stadium levels and the constraints of access. There may be 2 areas of a stadium in close proximity, but separation by an artificial barrier limiting access may increase staffing requirements.
The venue plan must include an appropriate number of trusted personnel with specific training. For instance, emergency physicians who serve as an EMS service director, usually have a good relationship to form the basis of a venue medical care team. In a field setting in particular, the paramedic and EMT are usually excellent venue team personnel. In the fixed medical station of a kiosk, nurses may be better suited.
In large venues, there may be a need for multiple physicians, including other members of an emergency medicine group. Multiple physicians may be required at large venues hosting multiple events, that is, a large outdoor concert venue with multiple stages. Equipment flexibility may also be required, that is, medically configured golf carts, all-terrain vehicles and bicycles.
Finally, the venue plan should describe the level of care to be provided on-site and off-site. At the very least, most venues require access to basic first aid and advanced life support. The level of expertise and on-site care will be partially determined by the expectations of the venue management. This level of care will determine the personnel needed as well as the supplies and equipment. Those decisions will guide the types of treatment, that is, suturing, respiratory nebulizers, narcotic pain medication, and even an on-site field hospital. Although one of the goals of venue medicine is to lesson the impact on local hospitals and EMS entities, another is to appropriately coordinate the transition of care between the venue and off-site resources.
Dr Ricardo Martinez, an emergency physician and founder of Medical Sports Group, has been a medical consultant to the NFL's Super Bowl for over 20 years. In order to develop a venue specific plan, Dr Martinez developed a template so that each venue may be adapted specifically to fit within a basic plan.38,39 The template consists of: leadership (administration), personnel, first responders, training, triage protocols, transportation, communications, on-site medical direction, medical aid stations/kiosks, hospital arrangements, access, equipment and supplies, quality assurance, disaster plan, and patient encounters (Box 52-1). Each of these components are specifically addressed next.
Box 52-1 Template for Development of Venue-Specific Plan |Favorite Table|Download (.pdf)
Box 52-1 Template for Development of Venue-Specific Plan
- Injury control
- Medical response
- Disaster planning
- First responders
- Medical direction
- Medical aid stations
- Quality assurance
A single person is responsible for the determination of the appropriate level of care at the venue. This leader must be adept at working with others at the venue including the venue administration, security, ushers, and vendors. The choices for this position can either be the physician in charge (medical director) or it may be someone in a high-ranking position with the EMS service (EMS director) that is working with the emergency physician. The leader assumes this responsibility and proactively prepare by holding frequent administrative meetings and addressing the questions and concerns of the venue administration. The effective leader is aware of and has a hand in every critical decision made by all personnel.
- Paramedics and EMTs with their field experience are excellent providers in this arena.
- Nurses are particularly suited for a fixed medical aid station.
- Emergency physicians are well trained to provide medical care at these events because of the spectrum of medical complaints.
Additionally, other personnel (administrative and clerical staff) may be valuable to
- Provide support in the aid station
- Obtain additional supplies
- Dispatch of mobile teams in the stadium
- Document and assess ongoing activities
First responders at the venues may be anyone from ushers or security people to vendors. It may be necessary to ensure that the first responders are trained in cardiopulmonary resuscitation (CPR) through a hospital or the American Red Cross. Paramedics, EMTs, or nurses deliver a higher level of care and provide appropriate backup. First responders can also be trained to use automated external defibrillators.
Specific training and education requires familiarization of personnel with the venue itself and the medical plan. For instance, paramedics and EMTs are shown the areas for which they will be responsible (including specific seating designations). The interactions and handoffs from security and ushers and to medical personnel are clarified. (Ideal response times to the most remote areas should be no more than 4 minutes.)
Venue triage should be developed under the direction of the lead physician. Triage decisions include
- Treatment in the spectator's seat
- Transport to medical station
- Transport directly to the hospital by ambulance
Specific clearly understood protocols can guide nonphysician personnel in the appropriate management of minor injuries and/or illnesses that do not require physician involvement. However, the physician is made aware of each encounter to limit liability and ensure the quality of care. Some medical plans allow a self-treatment option for patients requesting Tylenol or Band-Aids. In these circumstances, the spectators must sign liability release forms.
Transportation consists of 2 considerations:
- Transportation from a seat to a medical station
- Transportation by ambulance to the hospital
Ambulance stretchers may be placed at various locations within the venue or they may be dispatched from the medical aid station to the site of illness or injury. Wheel chairs and specifically designed stair chairs for stadiums may be necessary. The number of ambulances required varies, but in certain venues, 1 vehicle for every 10,000 to 20,000 spectators may be reasonable (some are defined by state mandate). However, with small venues, that is, 20,000 or fewer participants, arrangements must be in place to replace the single ambulance, if it is required to leave the venue to transport a patient. Some sports and their governing bodies require an ambulance dedicated to the field of play and will not allow competition without an on-site ambulance dedicated to the players.
The location of the ambulance will be somewhat determined by security. Optimally ambulances are located in close proximity to the first aid station on the ground level. Most large venues have an employee entrance or a loading dock that is typically a good site for the ambulance(s) to park. If a good site does exist in close proximity to the provision of medical care, then staging of an ambulance may occur. This staging requires specific communication protocols to bring the ambulance a designated venue location when needed for transport.
All routine communications occur on a single channel. The dispatcher is located in a central command post with venue administration, including the directors of operations, security, ushers, and other appropriate agencies such as fire and police. This dispatcher is able to communicate with all medical personnel in the venue on a single frequency. The medical director generally uses 2 frequencies, one each to communicate with
- Medical personnel
- Command staff in case of a disaster
The supervisor of the EMS personnel may need a separate frequency as well. Response teams each have at least one hand held radio per team. Each of the medical stations has a radio as well. These stations may also benefit from having a telephone line. Some stadiums use ring down phones that will only go from the medical station to the command post when utilized. If a more traditional land phone line is used, a 2-line system is necessary, allowing the aid station to receive a second incoming call while on the phone. By protocol, radio communication is only utilized for pertinent exchanges of information.
On-Site Medical Direction
The medical direction is ideally under the control of a single emergency physician providing on-site medical control. The medical director is intimately involved in all decision making at the venue and during the event is stationed either in the main aid station treating patients or in the central command post when multiple physicians are utilized. Proper placement of the medical director provides the highest level of medical care for the spectators and decreases liability. With small venues, not requiring on-site medical direction, the medical director may choose to
- Use online base station medical control
- Off-line medical control with standing protocols that have been set up under the medical director's guidance
Medical Aid Stations/Kiosks
Medical aid stations/kiosks are set up as a microcosm of the ED. Equipment and supplies available depend upon the scope of care as determined by the emergency medical director and the venue administration. Adequate space requires, at a minimum, the ability to treat 2 simultaneous cardiac arrests in the same area. Generally, a minimum of 800 ft2 is needed in order to have a place to treat patients adequately. Ideally, at least one station is available on each level of the stadium. If one level of a stadium has more than 30,000 to 40,000 people, then a second station should be considered.
Single level outdoors venue that are spread out place their stations in locations based upon crowd concentrations and distances between stations. Patients should not have to walk more than 5 minutes or approximately 1/8 of a mile to get to an aid station. In the case of a marathon, stations should be set up along certain mile increments with increasing number of stations and shrinking increments toward the end of the race.40 The concentration of medical personnel should be greatest at the end of the race, addressing the needs of both the spectators and the athletes.
Adequate signage is a venue wide priority and may require emphasis to the administration. Adequate signage clarifies to spectators where to go to seek medical care and how to activate the system by phone (in an enclosed suite). The ability for the spectator to self-present will decrease utilization of mobile team responses for nonemergent care.
An agreement with an appropriate hospital could address
- Transportation of the spectators for medical care
- Arrangements for supplies and equipment
- Communication protocols
- Disaster planning
Preferably, this hospital is the one nearest to the venue. A more distant hospital may be utilized for the majority of transports and stable patients can be transferred to a nearby hospital of choice. However, in the case of life-threatening emergencies, the nearest hospital must be utilized. On the specific days of the event(s), the predetermined trauma hospital is placed on alert.
Since the medical care staff are required to have unlimited access to all areas of the venue, it is necessary for the security staff to be familiar with medical personnel. A cardiac arrest can happen anywhere in the venue leaving no area off limits to the medical providers. The unlimited access may be requested as medical personnel are credentialed to the venue. A limitations related to the field of play may exist. However, if the medical team is responsible for the field of play, then specific credentials should designate that responsibility.
Most professional athletic teams have their own medical support staff to respond to the athletes. Backup arrangements and support, that is, EMS and emergency physician expertise should be addressed in advance. As mentioned, the NFL has a policy, which requires physician coverage for airway emergencies and rapid sequence intubation experience as needed for players, coaches, referees, and other personnel on the field.
The equipment and supply list can be developed in accordance with the services to be offered at the venue. Care beyond first aid at the venue, that is, suturing minor lacerations, requires a different set of supplies. As EMS field protocols evolve, future venues may even include advance ACLS (advanced cardiac life support) protocols, such as administration of thrombolytic therapy prior to transportation.
Large venues require access to airway equipment and drugs for ACLS. Intubation equipment, a defibrillator, and the full supply of ACLS drugs should be accessible at venues with multiple medical stations. IV fluids, specifically normal saline, should be available for trauma victims, dehydration, and the like.
Quality assurance is an important part of venue medical care and is the responsibility of the medical director. The program should have an ongoing focus on
- Reviewing the medical care delivered
- Identifying problem areas, both clinical and logistical
- Addressing all identified problems
It is necessary to log and document all encounters. Different types of providers may use individualized and specialized rapid assessment forms. Among the forms that should be available and ready are
- Documentation by physicians, nurses, paramedics/EMTs
- Against medical advice (AMA)/refusal of care
The medical (EMS) director(s) is responsible for the creation, use, and review of these forms. The cornerstone of quality assurance is proper record keeping and strong medical direction.
A disaster plan is designed that is specific to the venue and delineates appropriate response within the venue. The plan includes access to critical outside (off-site) resources for larger scale disaster. It is important to involve local and regional officials in charge of disaster planning for that particular area.
Staffing the venue is an inexact science. The variations described make it difficult to predict the number of likely encounters. Different studies acknowledge the wide variation in medical encounters, which are determined by a number of variables stated earlier including the site, environment, crowd size, crowd demographics, and alcohol availability.
There are published numbers ranging from 1.6% (160/10,000) to less than 0.01% (1/10,000) of attendees seeking medical care. Depending on the venue between 0.1% (10) and 0.5% (50) per 10,000 may be a safe starting point. The number of transports can only be estimated, that is, approximately 2% to 4% of the patients encountered may be transported.
A paramedic/EMT team can easily cover between 10,000 and 20,000 spectators as long as they are not dispersed over too large of an area. There should be at least 1 medical aid station on each level of the stadium with consideration for 2 if it is a very large venue or if there are greater than 30,000 people on one level. The best guideline for physician staffing is 1 to 2 physicians for every 50,000 spectators in a professional sports venue. With a high-profile event like the Super Bowl, Olympics, or World Cup, one physician may be placed in every aid station as well as designating a supervisory physician. An all-day outdoor rock concert in hot humid conditions requires additional physician staffing.
Staffing by response time is another approach. In most venues, ACLS is expected within 3 to 4 minutes. The faster the response, the better the outcome in a major medical situation, that is, survival from a cardiac arrest.
Contract acquisition may occur in a number of ways. An emergency medicine group is generally well positioned to submit a proposal. The group may have several physicians available to cover a venue with multiple events. Emergency groups that are well respected in the community can create a team with other critical personnel, including paramedics, EMTs, and nurses. Prior to submitting a proposal, the parties comprising the team should develop an agreed upon medical plan, with each group having a thorough understanding of the individual roles. The contract is submitted to the head of operations of the venue, or designee. The possible venue administrator may be a city, county, or state governmental agency or a private company. The venue administration will generally select the most appropriate team and may include representatives from any or all of the groups—physician group, EMS service, hospital, and so on.
The compensation may directly relate to the normal rates for that particular person's full time employment (see “Reimbursement” later). Alternatively, eager physicians may be willing to work for 50% or less of their normal rates. Nurses and paramedics may require their usual hourly rates from their full-time jobs. Often, the primary tenant, promoter, or venue manager assumes the costs or the medical plan.
When pursuing an agreement with a venue, quality must always be stressed. It is up to the physician leadership to promote the group's expertise to the interested party, providing a clear description of the high value of the medical care. Since many of these contracts are put out to bid, careful estimates of the costs of all personnel and supplies must be updated.
Once a venue contract is acquired, an excellent track record may lead to other contracts, if so desired. Continual communications with the head (senior administrator) of the venue operations will help develop the relationship necessary to maintain a long-term contract. Some administrators request a “hands-on” approach with frequent feedback, including a report after every event. Other administrators prefer quarterly or yearly reports.
Reports include essential information that summarizes the number of patients treated, their respective diagnoses, number of people transported, and any complications that occurred during events. Any patient (records) provided are “blinded” to ensure HIPAA (Health Insurance Portability and Accountability Act) compliance. If effectively communicated, a quality assurance process demonstrates the value of the quality medical care provided. The leader (medical director) is the primary contact person to address the administrator's questions and concerns. When specific problems arise, open communication to resolve problems is key.
The reimbursement of a team physician or a venue medical care provider is usually not commensurate hourly physician rates for work in the ED. While the importance of quality medical care for athletes and spectators is expected, emergency caregivers generally are paid at a lower than normal clinical rate. This may have in part led to attracting suboptimal providers without the skills and capacity to deliver urgent and emergency care to athletes and the spectators.
Under the theory, “You get what you pay for,” premium medical care with a true customer service approach may require appropriate compensation for the services requested. Without appropriate reimbursement, quality may suffer.
Minor venues, including dog shows and tractor pulls, may not receive the attention and support to attract the most qualified providers. Providers wishing to provide these services, perhaps because of an interest in the particular event, are often willing to accept lower reimbursement. However, the expertise of the provider affects the liability risk and should be discussed with the venue management, particularly when the venue includes a significant potential for liability.
The payment required to attract the highest quality personnel to a particular event/venue may be difficult to ascertain. Generally, nurses, paramedics, and EMTs are paid between 75% and 100% of their normal hourly wage. Physicians, with an interest in an event, often accept as little as 50% of their typical wage. Higher profile events, such as major sporting events or concerts, may be particularly attractive to individuals with a specific interest and are easier to staff, sometimes with volunteers. Unfortunately, over time even these events, when they take too much time from a practitioner's “real job,” become more of a chore than a pleasure and attracting quality personnel with low reimbursement will eventually become an issue. Additionally, volunteers rarely put in the effort to develop a sophisticated medical plan that may be necessary to effectively deal with the broad range of potential medical issues that may occur.
Team physicians may wish to negotiate a flat yearly rate or bill hourly for the time invested in caring for the team. Nonemergency team physicians, that is, orthopedists, may be able to generate additional income from surgical and/or office procedures. However, it is rare that this “spin-off” income generates enough money to compensate for the time these practitioners spend with the team. “Under-reimbursed” emergency physicians, with limited “spin-off” opportunities, may choose to bill for each encounter with an athlete. When considering this approach, the physician/group must assess whether the group or hospital contract permits this type of arrangement.
Until the practice of reimbursing physicians is widespread among venue medicine providers and athletic teams, it is up to the individual to promote the value of their services. The critical concepts to sell are
- Quality medical care
- Risk management and liability protection
- Customer service
- Membership of the overall administrative team
- 24 × 7 access to a broad range of service providers