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Mass gathering medical care

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Abstract

• Treatment facilities • Transportation resources • Public health elements • Access to care • Emergency medical operations • Communications • Command and control • Documentation • Continuous quality improve-
Mass Gathering Medical Care: The Medical Director’s Checklist
David Jaslow, MD, MPH, Arthur Yancey II, MD, MPH and Andy Milsten, MD
For
NAEMSP Standards and Clinical Practice Committee
January, 2000
What appear below in chronological order are the building blocks of a medical
action plan. Individual recommendations appear as bulleted points categorized as
Essential or Desirable within each component of the medical action plan. These points
are meant to serve as a guideline to aid in the effective planning of emergency medical
care delivery. Implementation of the various objectives is not directly addressed, since
this will depend on individual events, local EMS system design, personnel, resources and
event characteristics. Medical care that is well planned and organized should meet all of
the applicable essential points and most of the desirable points. In addition to the bulleted
points, each component of the medical action plan is prefaced by a brief definition and
overview of the section.
MEDICAL ACTION PLAN
The purpose of a medical action plan is to outline specific details about the
organization and delivery of emergency medical care at a mass gathering event. It should
be based upon a combination of experience and statistics from previous events of a
similar nature and duration coupled with objective evidence about elements known to
positively influence the delivery of emergency medical care at mass gathering events.
The medical action plan may be regulated or influenced by local, regional or state
guidelines concerning such planning activities.
Essential
A basic medical action plan must be created for every mass gathering event
The medical action plan must be the basis for the contractual agreement between the
Event EMS Director and the event sponsors
Authorship of the medical action plan is the responsibility of the Event EMS
Coordinator and the Event EMS Medical Director
The medical action plan must meet or exceed all local, regional and/or state
guidelines for mass gathering event EMS planning
Copies of the medical action plan must be forwarded to all local, regional, state and
federal officials who hold responsible roles in the mass gathering event
A copy of the medical action plan must be on-site and available to all EMS personnel
at the mass gathering event
The medical action plan must be reviewed and approved by the Event EMS Medical
Director or the medical director of the EMS agency primarily responsible for delivery
of emergency medical care at the mass gathering event
The medical action plan must include/address the following components:
Physician Medical Oversight
Medical Reconnaissance
Negotiations for Event Medical Services
Level of Care
Human Resources
Medical Equipment
Treatment Facilities
Transportation Resources
Public Health Elements
Access to Care
Emergency Medical Operations
Communications
Command and Control
Documentation
CQI
Desirable
The medical action plan should be completed at least 30 days prior to the mass
gathering event
The medical action plan should be distributed and reviewed with EMS personnel
prior to the mass gathering event
PHYSICIAN MEDICAL OVERSIGHT
The purpose of the medical oversight component of the medical action plan is to
define minimum recommendations for the position of Event Medical Director and its
requisite job requirements. Medical oversight at a mass gathering can be provided both
directly and indirectly, although the medical director’s presence, or that of his/her
designee, at the event is preferred for several reasons. First, the on-site physician medical
director signifies an organizational commitment to the delivery of appropriate emergency
medical care. Second, the emergency medicine literature clearly demonstrates that
physicians can positively impact decision-making in the field, especially when it
concerns potential non-transports and triage decisions. Third, the on-site physician
represents a part of the EMS community and can often function as its spokesperson or
champion for the often-unrecognized efforts of the mass gathering medical sector in
matters of resource acquisition. Physicians often wield more political clout than their
EMS providers. It may be easy to deny an EMS provider a request for additional
supplies, but it is much more difficult when a physician defends the request in the name
of appropriate patient care.
Physician Medical Oversight Plan
Essential
A basic plan for the provision of physician medical oversight must exist for every
mass gathering event
Such a plan must address aspects of direct and indirect medical oversight functions
applicable to mass gathering events
Such a plan must ensure that EMS providers have appropriate supervision and/or
guidance from a medical command/control authority to safeguard delivery of
appropriate emergency medical care
Requirements for the Physician Medical Director
Essential
A physician medical director must be appointed or confirmed by the event
administrator or venue owner, if not already self-designated, for every mass gathering
event
The medical director must possess a valid medical license from the state in which the
event is being held
The medical director must commit to the time required to plan and direct emergency
medical care at the event
Desirable
The medical director should possess experience as the medical director of an EMS
service or agency
The medical director should be knowledgeable and experienced in the care of acutely
ill and injured patients
The medical director should be board eligible/board certified in emergency medicine
The medical director should have previous experience in the oversight of mass
gathering medical care
The medical director should be on-site as much as possible during the mass gathering
event
Indirect Medical Oversight
Essential
The medical director must participate in the design of a medical oversight plan for
every mass gathering event
The medical director institute protocols as part of this plan to ensure that uniform and
standard emergency medical care is delivered at the mass gathering event
A mechanism must be in place for the indirect physician supervision of all event
medical personnel if the medical director will be off-site or remote from the event
An organizational chart and reporting structure regarding medical oversight
responsibilities must be included in the plan
Desirable
The organizational chart should include the number, function and reporting pathways
for each EMS position which will exist at the event
Direct Medical Oversight
Essential
The medical director must be continuously available by some form of communication
to all EMS personnel for whom he/she is responsible during the course of the mass
gathering event
Any physician designated to fulfill the medical director’s role on-site must be
knowledgeable of the details regarding administration and planning of medical care
for the mass gathering event
Desirable
The medical director providing direct medical oversight functions should not become
personally involved in the care of individual patients unless an extraordinary
circumstance exists
The medical director should be readily and easily identifiable by uniform, command
vest or other item of clothing
MEDICAL RECONNAISSANCE
The purpose of the medical reconnaissance component of the medical action plan
is to present objectives that will aid the Event EMS Coordinator and EMS Medical
Director in the successful response to medical emergencies at a mass gathering event
through careful analysis of elements related to morbidity. Many of these variables are
suspected of having a direct or indirect relationship to the number of patients seen at a
mass gathering event, although few definitive statements can be made at this time due to
the lack of prospective studies. Nonetheless, the importance of proper evaluation and
preparedness for a mass gathering event cannot be overemphasized, especially given the
number of case reports in the medical literature which appear to identify event
characteristics related to illness and injury.
Additionally, a thorough inspection of the venue site and an evaluation of the
impact of the event on the operations of the local EMS system must be conducted prior to
the event. The Event EMS Medical Director must have a sufficient understanding of the
EMS system and its capabilities in order to predict where problems might arise and how
an additional patient load will affect EMS operations.
Medical Reconnaissance Plan
Essential
A basic medical reconnaissance plan must exist for every mass gathering event
Such a plan must identify key facts about the mass gathering event including, but not
limited to, the following:
Venue location
Venue characteristics
Expected attendance
Available medical resources
Such a plan must identify factors likely to adversely affect patient volume including,
but not limited to, the following:
Crowd demographics
Expected weather conditions
Risk for violence
Alcohol and drug use
Availability of food, water and shelter
Desirable
Such a plan should address mitigation strategies to handle increases in patient volume
which may be due to one or more of the following factors:
Crowd composition
Crowd volume
Crowd density
Crowd mood
Crowd control
Crowd mobility
Physical barriers to crowd access
Aisle space
Time to access victims in different areas of the venue
Entrance and exit locations for spectators and participants
Characteristics of event participants
Location, geography and characteristics of the venue site
Outdoor versus indoor events
Nature of the event
Event duration
Warm ambient temperature and heat-related illnesses/injuries (outdoor events)
Cold ambient temperature and cold-related illnesses/injuries (outdoor events)
Sudden or unexpected changes in temperature (outdoor events)
Precipitation (outdoor events)
Threat of thunderstorms with lightning
Wet or slippery versus dry ground conditions (outdoor events)
Availability and/or use of alcohol
Availability and/or use of illicit drugs
Availability of water
Availability of food
Availability of shelter
Availability of emergency medical services
Ingress and egress routes for emergency vehicles
Law enforcement and/or venue security presence
Threats against the event or other security concerns
VIPs in attendance
Potential for violent group behavior
Likelihood for technological disaster occurring during the event (plane crash, etc.)
Venue and Event Analysis: Information Gathering Prior to the Event
Essential
The event date, location and duration must be known
The event site must be visited by the Event EMS Coordinator of his/her designee
The extent to which emergency medical care can and will be provided must be known
The responsibility for delivery of emergency medical care to specific groups or sub-
groups within the overall event population must be agreed upon by all parties
concerned
Operational characteristics and command structure of the jurisdictional 9-1-1 EMS
agency must be reviewed
The distances and predicted transport times to receiving hospitals must be known
Regional traffic flow patterns and impact upon EMS transport units must be evaluated
All regulations governing mass gathering medical care, fire codes, safety codes,
public health codes and any other applicable local and state regulations must be
reviewed prior to the event
Desirable
The Event EMS Coordinator and/or Event EMS Medical Director should attend
similar events prior to the one being planned to evaluate elements contributing to
successful or problematic EMS delivery
The Event EMS Coordinator and/or Event EMS Medical Director should review
medical and operational records from previous similar events to evaluate elements
contributing to successful or problematic EMS delivery
NEGOTIATIONS FOR EVENT MEDICAL SERVICES
Agreements to provide emergency medical care at the majority of smaller mass
gathering events are usually solidified after a single phone call or letter to the local EMS
agency. However, a casual approach may ignore certain medicolegal and logistical
complications that could impair successful EMS delivery. For large-scale mass
gatherings, the planning process may span weeks to months and involve meetings with
various event representatives. It is incumbent upon the Event EMS Medical Director and
the Event EMS Coordinator to ensure that venue owners and managers understand the
complexities of mass gathering medical care delivery. They must fully support the
implementation of a plan to provide patients with state-of-the-art care. They must also
provide medical personnel with the equipment and logistical support necessary to
accomplish this goal.
Liability coverage and compensation for medical personnel are two subjects that
should receive special attention. The event managers should take primary responsibility
for assurance of appropriate liability coverage for all medical personnel. Liability
insurance may be provided through each individual’s previously existing plan, their
employer’s institutional plan or by the event organization. However, reliance on so-called
Good Samaritan statutes is risky, especially if medical personnel receive any form of
compensation for their services and when their services were procured with advance
notice.
Compensation for services rendered will be monetary or non-monetary. For many
smaller events, participation in the event itself and a “free lunch” usually guarantees
availability of volunteers. However, it is unlikely that municipal or privately contracted
EMS personnel will be interested in providing services free of charge. The costs of
participation as well as the delivery of service must be calculated and passed on to the
venue management whenever possible. Any added benefits, such as souvenirs or event
tickets for family/friends, may also generate enthusiasm among medical personnel.
Essential
The Event EMS Coordinator must meet with the venue managers/owners prior to the
event
A contractual agreement must be in place that delegates responsibility for the delivery
of emergency medical care to the appropriate agency or authority
Scope and responsibility for emergency medical care must be clarified
Issues regarding licensing and authority to practice for medical personnel must be
clarified
Liability insurance coverage for the physician medical director and all EMS
personnel must be addressed
Compensation status for all medical personnel must be addressed
The number and type of medical personnel necessary and desirable for event
coverage must be agreed upon prior to the event
Responsibility for financing and procurement of medical resources must be addressed
Command and control issues and reporting relationships for medical personnel must
be addressed
Desirable
The Event EMS Medical Director should either meet with or talk to venue
owners/event managers both as a courtesy and to demonstrate commitment to the
delivery of emergency medical services
The Event EMS Coordinator should coordinate and critique all aspects of emergency
medical care with the event planning committee and event director both before and
after the event
Human resource logistics issues, such as provision of meals, parking and lodging,
should be discussed with venue managers/owners
Media coverage for EMS sponsoring organizations should be sought
LEVEL OF CARE
The level of care component of the medical action plan defines minimum
standards for emergency medical capability at a mass gathering event and preferred
sophistication of the medical sector.
Level of Care Plan
Essential
A basic level of care plan must exist for every mass gathering event
Such a plan must address the sophistication of the medical sector (i.e. capabilities)
Such a plan must state that the minimum level of care to be provided is at the EMT-
Basic level, which includes the ability to deliver CPR and early defibrillation
Such a plan must specifically address how early defibrillation capability will be
designed to meet a collapse-to-shock goal of 5 minutes or less
Such a plan must explicitly state whether or not advanced life support care is
available at the event
Such a plan must address the need for education/training of EMS providers regarding
unusual medical protocols or procedures prior to the actual event
Such a plan must be reviewed and approved by the Event EMS Medical Director
A detailed map of the event or venue site must be created to show where both basic
and advanced life support capability is located
Desirable
The level of care available at a mass gathering should must reflect that which is
available in the community
Availability of advanced life support and the capability to deliver ACLS is always
preferred at any mass gathering event
When limited advanced life support resources are available at an event, they should
be located in a fixed position rather than remaining mobile
Emergency Medical Capabilities
Essential
Emergency medical providers delivering both basic and advanced life support at a
mass gathering event must be capable of recognition of abnormal signs and
symptoms, preliminary diagnosis (if possible) and initiation of treatment for the
following conditions:
Abdominal pain/problems
Airway obstruction
Allergic reaction
Altered mental status
Animal bites
Back pain (traumatic and non-traumatic)
Burns
Cardiac/Respiratory arrest
Cerebrovascular accident (CVA)
Chest pain and cardiac symptoms
Diabetic emergencies
Electrocution
Environmental emergencies
Hazardous materials incidents with patient complaints
Headache
Hemorrhage (internal and external)
Near-drowning and water-related trauma
Ophthalmologic illness and injury
Overdose/poisoning
Pregnancy problems/labor and delivery
Psychiatric emergencies
Respiratory distress
Seizures
Syncope
Traumatic injuries
Development of Protocols and Standard Operating Procedures
Essential
The Event EMS Director must ensure that all non-physicians deliver medical care
according to an accepted set of protocols and standard operating procedures
Such policies must be approved prior to the event by the Event EMS Medical
Director
Patients whom are treated and released must be cleared either by a physician or an
individual delegated by the Event EMS Medical Director to make such a decision
The Event EMS Medical Director and the Event EMS Coordinator must ensure that a
policy is in place regarding the care of minors who present to the medical sector for
evaluation and/or treatment without a parent or legal guardian
All medical personnel must be educated about event protocols and policies prior to
the beginning of event coverage
Desirable
Protocols and standard operating procedures should adhere to local or regional
practice if event-specific policies have not been developed
Early Defibrillation Capability
Essential
The Event EMS Coordinator and the Event EMS Medical Director must evaluate the
capability of EMS personnel to respond to cases of sudden cardiac death in order to
maximize the chances of survival
Such evaluation must be based on the following factors:
Predicted incidence of cardiac arrest
Predicted delays in activation of the EMS system
Predicted frequency of bystander CPR
Availability of AEDs for use by lay persons or bystanders
Predicted delays in arrival of personnel trained in early defibrillation
Availability of early advanced life support
Predicted transport times to definitive care
Every effort must be made to deliver early defibrillation to victims of sudden cardiac
death within 5 minutes from the time of collapse
Such efforts will likely involve analysis and improvement of multiple EMS system
elements, which should be based upon published studies regarding cardiac arrest and
prehospital response
HUMAN RESOURCES
The exact numbers of emergency medical personnel necessary to deliver
appropriate care at fixed treatment facilities and to provide roving coverage that will
guarantee rapid response for life-threatening medical emergencies will differ for every
mass gathering event. Thus, it is impossible to present a mathematical formula that will
accurately predict staffing requirements. More importantly, staffing goals for mass
gathering events should emphasize as many personnel as possible both to avoid
burdening the local EMS system and to be prepared for mass casualty incidents.
The purpose of the human resource component of a medical action plan is to
define roles and responsibilities of medical personnel and logistical issues surrounding
their deployment. A comprehensive human resource plan will address numbers and types
of medical personnel necessary to provide acceptable emergency medical care relative to
the specific event. It will also detail how the personal needs and compensation of these
personnel will be handled.
Human Resource Plan
Essential
A basic human resource plan must exist for every mass gathering event
The human resource plan must clearly indicate a chain of command
The human resource plan must clearly delineate the medical care responsibilities for
all personnel who may participate in such care
The human resource plan must clearly indicate roles and responsibilities for personnel
with advanced medical training (physicians, etc)
The human resource plan for large scale events must clearly indicate how personnel
management issues will be addressed, including, but not limited to, the following:
Work cycles (shift rotation)
Check-in and credentialing procedures
Hydration and alimentation
Rest and/or sleep
Back-up scheduling
A map of the venue site with locations of all deployed BLS and ALS medical
personnel must be created and stored at the command post
Desirable
Copies of this map should be distributed to all medical personnel
Consideration should be given to designation of a personnel manager for large scale
events
Level of Training
Physician
Essential
Physicians charged with direct patient care responsibilities must be currently licensed
in the state in which the mass gathering event is being held
Physicians charged with direct patient care responsibilities must be recognized by the
Event Medical Director to provide care
Physicians charged with direct patient care responsibilities must be certified in CPR
and ACLS or demonstrate that they have the requisite knowledge to handle
emergencies that are covered within these training courses
Physicians charged with direct patient care responsibilities must be experienced in the
care of patients with life and limb-threatening illnesses and injuries
The on-site physician must be immediately available when requested to assist in
patient care or evaluation
Desirable
Use of on-site physicians is strongly encouraged in the following circumstances:
Sophisticated medical care facilities on-site (radiography, EKG, etc.)
Limited transportation resources
Large numbers of spectators and/or participants (potential for large patient
volume with broad variety of medical problems)
Significant risk for the development of life and/or limb-threatening illness or
injury (auto racing, equestrian events, boxing, etc.)
Long transport times to definitive care facilities
If physician care is available on-site, medical personnel should be aware whether
their primary responsibility is direct patient care or consultation
The on-site physician should be present within the designated treatment area as much
as possible during the event
One or more physicians trained, board-certified, or practicing in emergency medicine
should be on-site if physician level care is provided at an event
Physicians charged with direct patient care responsibilities should be currently
certified in PALS and ATLS or demonstrate that they have the requisite knowledge to
handle emergencies that are covered within these training courses
Physician Extenders (PA, CNP)
Essential
The role of the physician extender at a mass gathering event is primarily treatment of
ambulatory patients with non-critical complaints
Physician extenders must be directly supervised by an appropriately licensed and
qualified physician
Physician extenders charged with direct patient care responsibilities must be currently
licensed in the state in which the mass gathering event is being held
Physician extenders charged with direct patient care responsibilities must be
recognized by the Event Medical Director to provide care
Physician extenders charged with direct patient care responsibilities must be currently
certified in CPR and ACLS
Desirable
Use of on-site physician extenders may be appropriate in the following
circumstances:
Sophisticated medical care facilities on-site (radiography, EKG, etc.)
Limited transportation resources
Large numbers of spectators and/or participants (potential for large patient
volume with broad variety of medical problems)
Long transport times to definitive care facilities
Physician extenders should primarily be utilized within fixed treatment facilities
Physician extenders charged with direct patient care responsibilities should be
experienced in the evaluation and treatment of patients with acute medical complaints
Nurse (RN, MICN)
Essential
The role of the nurse at a mass gathering event is primarily assistance in the treatment
of acutely ill and/or injured patients
Nurses must be directly supervised by an appropriately licensed and qualified
physician
Nurses charged with direct patient care responsibilities must be currently licensed in
the state in which the mass gathering event is being held
Nurses charged with direct patient care responsibilities must be currently certified in
CPR and ACLS
Desirable
Nurses should not independently evaluate and treat patients unless they have
recognized prehospital credentials, such as a flight nurse or prehospital nurse
Nurses should primarily be utilized within fixed treatment facilities
Nurses charged with direct patient care responsibilities should be experienced in the
evaluation and treatment of patients with acute medical complaints
Nurses charged with direct patient care responsibilities should be knowledgeable in
mass gathering medical care
Nurses charged with direct patient care responsibilities should be familiar with the
incident command system and mass casualty incident response
Nurses should be charged with medication dispensation and tracking, if available
EMT-Intermediate and EMT-Paramedic
Essential
The role of the EMT-Intermediate and EMT-Paramedic at a mass gathering event is
primarily evaluation and treatment of acutely ill and/or injured patients who require
advanced life support work-up or invasive medical therapy
EMT-Intermediates and EMT-Paramedics charged with direct patient care
responsibilities must be currently certified or licensed in the state in which the mass
gathering event is being held
Desirable
Use of EMT-Intermediates and EMT-Paramedics is strongly encouraged in the
following circumstances:
Limited transportation resources
Large numbers of spectators and/or participants (potential for large patient
volume with broad variety of medical problems)
Significant risk for the development of life and/or limb-threatening illness or
injury (auto racing, equestrian events, boxing, etc.)
Long transport times to definitive care facilities
EMT-Intermediates and EMT-Paramedics should be utilized both within fixed
treatment facilities and as mobile emergency responders
EMT-Intermediates and EMT-Paramedics should be knowledgeable in mass
gathering medical care
EMT-Intermediates and EMT-Paramedics should be familiar with the incident
command system and mass casualty incident response
EMT-Basic
Essential
The role of the EMT-Basic at a mass gathering event is primarily evaluation and
treatment of acutely ill and/or injured patients who require only minor or
uncomplicated treatment, unless there is no advanced life support capability available
EMT-Basics charged with direct patient care responsibilities must be currently
certified or licensed in the state in which the mass gathering event is being held
Desirable
EMT-Basics can be utilized within fixed treatment facilities, but they should be
utilized primarily as mobile emergency responders when ALS capability is available
within fixed treatment facilities
EMT-Basics charged with direct patient care responsibilities should be
knowledgeable in mass gathering medical care
EMT-Basics charged with direct patient care responsibilities should be familiar with
the incident command system and mass casualty incident response
Volunteers and Ancillary Medical Personnel (not trained to the EMT-B level)
Essential
Volunteers and ancillary medical personnel must know how to summon or alert
properly trained emergency medical care providers
Desirable
Volunteers and ancillary medical personnel should serve as scribes, spotters or in
other positions which do not require direct patient care responsibility
Volunteers and ancillary medical personnel should be trained in CPR and basic first-
aid if patient contact is anticipated
Number of Personnel
Essential
A minimum number of emergency medical personnel must be on-site to treat the
volume of patients expected according to medical reconnaissance, statistical estimates
and experience from previous events
Sufficient numbers of appropriately trained personnel must be on-site to deliver
emergency cardiac care to anyone suffering sudden cardiac death within the
geographic boundaries in which care is to be provided and within 5 minutes from the
time the first call for assistance is placed
Desirable
Sufficient numbers of appropriately trained personnel should be present within fixed
treatment facilities to fulfill the following functions (one person may occupy more
than one position):
Triage
Evaluation and treatment
Medical record keeping
Communications
Logistics
Credentialing
Essential
All medical personnel must be appropriately certified/licensed and credentialed to
practice their medical specialty
All local, regional and state regulations regarding prehospital care must be followed
All medical personnel must have some form of identification (preferably photo I.D.)
attached to their uniform or person
Desirable
Verification of medical credentials should be performed prior to the day of the mass
gathering event
Compensation
Essential
Medical personnel must never withhold emergency medical care to persons at a mass
gathering event due to the inability of the patient to pay for services
Medical personnel must never request payment on-site for the delivery of emergency
medical care
Desirable
Medical personnel should receive some form of compensation for their services
This compensation should be distributed equitably
Deployment Scheme
Essential
Emergency medical personnel must be deployed in such a way that guarantees arrival
of basic life support personnel with defibrillation capability at a patient’s side within
4-5 minutes of a request for aid 90% of the time
Medical personnel deployed in the field must maintain constant radio or visual
contact with their supervisors or the command post
Advanced life support personnel are best utilized within fixed treatment facilities
unless there are ample providers available to permit roving advanced life support
teams without compromise of fixed treatment facility capabilities
Deployment of emergency medical personnel must occur before the event begins; the
exact time should be determined by the Event EMS Director in conjunction with the
venue administrators
Dismissal of emergency medical personnel must not occur before the event ends; the
exact time at which personnel may be demobilized should be determined by the Event
EMS Director in conjunction with the venue administrators
Desirable
Roving teams of emergency medical personnel should be deployed proactively to
monitor for emergency medical incidents during events in which there is significant
crowd density or other factors which may limit response times or access to patients
Emergency medical personnel should be assigned to care for either the spectators or
the participants at events in which there is a likelihood that participants will become
ill and/or injured in order to avoid compromising medical coverage for one group or
the other
Logistics
Essential
The Event EMS Director must determine whether a designated medical sector
logistician(s) is necessary to distribute and monitor supplies
The Event EMS Director or the medical sector logistician must ensure that the
necessary quantity and type of supplies have been procured prior to the event
The Event EMS Director or the medical sector logistician must ensure that there is
continuous availability of critical medical supplies during the event
The Event EMS Director or the medical sector logistician must ensure that
distribution of supplies occurs in a timely and efficient manner
Desirable
One or more designated logisticians should be assigned to the medical sector at large
scale events to handle the following tasks:
Procurement and distribution of all supplies and pharmaceuticals
Tracking of inventory and maintenance of appropriate levels of supplies
Collection and return of unused supplies
Collection of patient care reports (PCRs)
Transportation routes for delivery of supplies should be planned ahead of time and
should take into account the density, mobility and location of the crowd and the
terrain to be traversed
Training
Essential
The Event EMS Director and the Event EMS Medical Director must determine
whether emergency medical personnel will require specialized training prior to the
beginning of the event
Desirable
The Event EMS Director should review the mass casualty plans with all emergency
medical personnel prior to the event
MEDICAL EQUIPMENT
The medical equipment component of the medical action plan defines the
minimum necessary medical equipment and suggestions for its deployment. It is
impossible to suggest minimum quantities for the recommended items since this will
differ for every event. Note that the majority of basic and advanced equipment
corresponds to what is typically carried on a basic life support ambulance and advanced
life support ambulance, respectively.
The pharmaceutical list is a difficult one to design due in part to the fact that
every state has different regulations regarding the administration of medications by
paramedical personnel. Clearly, advanced life support providers should be prepared to
utilize their entire armamentarium if needed at a mass gathering event. Under no
circumstances should they dispense or administer medications that they are neither
familiar with nor trained and certified to deliver. Additionally, the use of analgesics,
antiemetics and airway management drugs must be closely monitored either directly or
indirectly (medical command contact) by the Event Medical Director, since patients who
require these agents may be critically ill.
The use of “emergency department” equipment and pharmaceuticals is rare at
mass gathering events and likely limited to those extremely large and well-funded events
at which a constant physician presence is guaranteed. Indeed, several events, including
the Indianapolis 500, actually boast an on-site hospital. The items listed below are meant
only to serve as a guide for those medical directors and EMS directors unsure how to
approach delivery of medical care at a mass gathering event. They are not meant to
replace equipment and pharmaceutical lists at well-planned annual events that have
unusually sophisticated medical care delivery systems. Since fixed treatment facilities
may span a spectrum of complexity from simple tents under which paramedics deliver
standard EMS care to specially built mini-hospitals, there are no essential items listed
under “Fixed Treatment Facility Medical Equipment” and “Fixed Treatment Facility
Pharmaceuticals.”
Medical equipment cache design, prioritization and management are important to
the overall functioning of the medical sector. Large or prolonged events may dictate that
someone be assigned as logistician to effectively manage equipment stocking and
deployment issues. This person is best designated prior to the event so that he/she may
become familiar with the equipment and plans for its deployment.
Medical Equipment Plan
Essential
A basic medical equipment plan must exist for every mass gathering event
Such a plan must make reference to the highest level of care that is anticipated to be
delivered at the mass gathering event, the amount and type of equipment that will
enable this goal to be met and a deployment scheme for such equipment
Such a plan must include a point-of-contact and/or phone number to request
additional supplies and equipment
Ability to deliver medical care at the EMT-Basic level to all spectators and
participants, including early defibrillation, is the minimum acceptable standard for a
mass gathering event
All local, regional and state regulations must be met or exceeded when developing a
plan for use of medical equipment at a mass gathering event
Desirable
Stockpiling of additional supplies and equipment is strongly encouraged at every
mass gathering event
The Event EMS Director should dictate to mobile EMS crews and responders what
pieces of equipment and/or medical devices will be carried on field responses
Medical Equipment-Basic
Essential
Basic diagnostic and therapeutic equipment must be immediately available for both
adult and pediatric patients
The following items are considered essential elements of this equipment cache:
Airway adjuncts
Nasopharyngeal (adult and pediatric sizes)
Oropharyngeal (adult and pediatric sizes)
Alcohol swabs
Bag-valve masks (adult and pediatric sizes)
Backboards, rigid
Bandages, elastic
Bandages, triangular
Band-aidsâ
Cervical collars, rigid (adult and pediatric sizes)
Cold packs, disposable
Defibrillator, automated
Gauze pads (multiple sizes)
Gloves, latex, nonsterile (multiple sizes)
Gloves, not latex, nonsterile (multiple sizes)
Hot packs, disposable (seasonal)
Klingâ (multiple sizes)
Obstetric pack
Oxygen delivery devices (nasal cannula, nonrebreather)
Restraints, soft
Shears, trauma-style
Sling and swath
Splints (finger, wrist, forearm, lower extremity, traction)
Stethoscope
Sphygmomanometer
Suction device, portable (with charger, if necessary)
Suction supplies (catheters, disposable bags, etc.)
Tape, adhesive (multiple sizes)
Tongue blades
The Event Medical Director must decide whether or not EMT-assisted medications
and any other specialized medical equipment will be included in the cache for use at
the mass gathering event
Desirable
Patient comfort items should be available and may include urinals, bedpans, facial
tissues, feminine hygiene products, sunscreen, lip balm, and other similar products
Medical Equipment-Advanced
Essential
If advanced life support level of care is available, appropriate diagnostic and
therapeutic equipment must be immediately available for both adult and pediatric
patients
The following items are considered essential elements of this equipment cache:
Blood glucose test strips and meter
Cardiac monitor with manual defibrillator and external pacemaker
Cricothyrotomy kit or supplies
Devices to confirm intubation (CO2 detector or esophageal detector device)
Endotracheal tubes of assorted sizes
Intravenous access devices and tubing
Laryngoscope with assorted blades and Magill forceps
Pulse oximeter
Razors
Thoracostomy kit or supplies
Medical equipment not commonly used within local EMS practice must be approved
by the Event Medical Director prior to the event
Desirable
Whenever possible, duplicate sets of ALS equipment should be available
The following items are considered desirable elements of this equipment cache:
12-lead EKG capability
Alternative advanced airway devices (Combitubeâ, lighted stylet, etc.)
Automated blood pressure monitor
Automated ventilators for prehospital use
Broselow tape
End tidal CO2 monitor
Intravenous fluid infuser (disposable or automated)
Pharmaceuticals
Essential
If advanced life support level of care is available, a standard ALS pharmaceutical
regimen must be immediately available
Such a regimen shall include the following commonly used prehospital medications:
ACLS medications
Adenosine
Atropine
Bretylium (may be deleted in favor of Amiodarone)
Calcium chloride
Calcium channel blocker (if approved by local protocol)
Dopamine (pre-mixed bag preferred)
Epinephrine 1:10000 concentration
Lidocaine
Sodium bicarbonate
Analgesics
Aspirin (use for ischemic chest pain may be allowed by local protocol)
Narcotic for parenteral administration
Anaphylaxis medications
Antihistamine for parenteral administration
Epinephrine, 1:1000 concentration
Antiepileptics
Benzodiazepine for parenteral administration
Asthma medications
Beta agonist for nebulization
Steroid preparation (parenteral agent preferred; use may be allowed by local
protocol)
Cardiac medications
Nitroglycerine, sublingual (tablets or spray)
Loop diuretic for parenteral administration
Diabetic medications
Dextrose, 50%
Glucagon
Emetic
Syrup of ipecac (if approved by local protocol)
Intravenous solutions
Crystalloid solutions
Pharmaceuticals not commonly used within local EMS practice must be approved
ahead of time by the Event EMS Medical Director
Desirable
Pre-filled syringes for commonly used pediatric medications should be available
Non-medical Equipment
Essential
Hospital-type exam tables, beds and/or stretchers/cots
Sheets
Blankets
Dedicated and properly marked hazardous waste receptacles
Non-hazardous waste receptacles
Spare batteries for battery-powered devices
Pens
Paper
Patient care forms
Desirable
Chairs for medical personnel
Bathroom with sink and toilet dedicated to the medical sector and/or treatment facility
Linen disposal or recycle bin
Pillows
Towels
Diapers
Patient identification bracelets
Safety pins
Refrigerator (essential item if refrigerated pharmaceuticals are being used)
Fixed Treatment Facility Medical Equipment (assumes physician-level care)
Desirable
The following items are considered desirable elements of this equipment cache:
o Benzoin
o Betadine
o Burn dressings
o Cotton applicators and balls
o Dermabondâ or equivalent
o Eye examination equipment
o Eye patches
o Chest tubes, chest tube trays and pleurevacs
o IV poles
o IV pumps
o Nasogastric tubes
o Ophthalmoscope
o Otoscope
o Prescription pads
o Ring cutters
o Splinting supplies
o Steri-stripsâ
o Suture kits and suture material
o Thermometers
o Vaselineâ gauze
o Woods lamp
Fixed Treatment Facility Pharmaceuticals (assumes physician-level care)
Desirable
The following items are considered desirable elements of this pharmaceutical cache:
Analgesics
Anesthetics, local
Antacids
Antibiotics
Intravenous agents
Ointment
Oral agents
Antidiarrheal agents
Antiemetic (parenteral and/or suppositories)
Antiepileptics
Airway management agents
Induction agents
Paralytic agents
Asthma medications
Steroid preparation (parenteral agent preferred; EMS use may be allowed by
local protocol)
Burn medications
Silver sulfadiazine cream
Xeroformâ gauze
Cardiac medications
Beta blockers (parenteral)
Calcium channel blockers (parenteral)
Digoxin (oral or parenteral)
Diabetic medications
Insulin, regular
Intravenous solutions
D50.9NS
D50.45NS
Opthalmic agents
Anesthetic
Antibiotic ointment
Fluorescein strips
Irrigating solution
Mydriatic agent
Poisonings
Activated charcoal (EMS use may be allowed by local protocol)
Staging and Deployment of Equipment
Essential
A plan for the staging and deployment of medical equipment must be created and
reviewed prior to the event
All equipment and pharmaceuticals must be propositioned at the beginning of the
event equipment and pharmaceuticals must be known to key personnel and tested by
the Event EMS Director and/or a dedicated medical logistician prior to the beginning
of the event
The mechanisms to deliver and replenish equipment and pharmaceuticals must be
known to necessary personnel
Only properly credentialed individuals can be allowed to access and deliver
prescription pharmaceuticals
Cold chain storage of pharmaceuticals must be preserved
Desirable
Medical personnel should be dedicated to logistics and resupply for high-volume
events in which this function is not handled by venue personnel
TREATMENT FACILITIES
The purpose of the treatment facility component of the medical action plan is
twofold. First, there must be a clearly defined plan to deliver critically ill and/or injured
patients to definitive care. Second, establishment of on-site treatment facilities must be
guided by criteria that ensure a safely constructed environment which is efficient for
medical personnel and maximally therapeutic for patients.
On-site treatment facilities are generally needed only for large mass gathering
events, those that are planned for a lengthy period of time, those in which it is predicted
that patient volume will be high and those in which an excessive transport time to off-site
treatment facilities exists. On-site treatment facilities can be as simple as a tent in which
basic care is offered and there is a place for patients to lie down or as comprehensive as
freestanding emergency departments. The exact configuration will depend on the
predicted needs of the event patient population and available human and financial
resources. Important elements to consider when designing on-site treatment facilities
include safe construction of the entity, communications requirements, medical and non-
medical equipment needs, barrier-free access.
Off-site treatment facilities are usually the primary destination for persons who
require definitive care at a mass gathering event. Hospitals and other acute care facilities,
which may be transport destinations should be evaluated for their ability to handle
specialty situations.
Treatment Facility Plan
Essential
A basic treatment facility plan must exist for all mass gathering events
Such a plan must address both on-site and off-site treatment facilities
Such a plan must address the physical characteristics and logistics of any on-site
treatment facilities which are planned for the event
Such a plan must address the capability of off-site treatment facilities to handle the
expected patient load, including specialty patients, such as critical trauma and
hazardous materials patients
Desirable
On-site treatment facilities should be established whenever analysis of variables
related to patient generation and care indicate that a significant patient load is
possible
Off-site treatment facilities should include regional referral centers, as well as local
acute care facilities
On-Site Treatment Facilities
Physical Characteristics (Construction)
Essential
On-site treatment facilities must be constructed to withstand predictable weather
conditions during the event
On-site treatment facilities must protect the occupants from possible adverse weather
conditions, including extremes of heat and cold
On-site treatment facilities must be constructed to minimize the extremes of patient
temperatures
Desirable
On-site treatment facilities should offer privacy for at least one patient at a time
Communications
Essential
On-site treatment facilities must have two-way communications capability with the
Command Post
Desirable
Redundant communications modes, such as radio and telephone, should be available
to medical personnel within on-site treatment facilities
Medical Equipment and Pharmaceuticals
Essential
On-site treatment facilities must have sufficient medical equipment to begin the initial
treatment of all common medical emergencies listed under Level of Care
On-site treatment facilities must have medical equipment of a quality consistent with
the highest standards offered in the surrounding community
On-site treatment facility personnel must ensure the safety, sanitation and readiness of
their medical equipment and pharmaceuticals
Desirable
On-site treatment facilities should have their own cache of medical supplies, although
they may be stocked with equipment from an ambulance
The operations of on-site treatment facilities should not depend on key pieces of
equipment from an ambulance that may leave the venue with a patient
Non-medical equipment
Essential
A sufficient number of cots and chairs must be available for the anticipated patient
volume
Medical waste must be disposed of properly
Desirable
A sufficient number of chairs should be available for medical personnel to rest
One or more tables should be available for writing and storing supplies
Level of Care
Essential
On-site treatment facilities must offer a level of care at least equivalent to basic life
support
Desirable
Advanced life support care should be available at every on-site treatment facility, if
possible
Staffing (Human Resources)
Essential
At least one medical provider qualified to deliver the highest level of care capable at
the on-site treatment facility must be present at all times during the operating hours of
that facility
A predetermined chain of command and responsibility must be instituted in each on-
site treatment facility
Adequate medical personnel must be assigned to each on-site treatment facility based
on predicted patient volume
Desirable
Advanced life support providers assigned to on-site treatment facilities should not
leave these facilities to retrieve patients; patients should be brought to the facilities by
basic life support providers (preferably) or other personnel
Patient Access
Essential
On-site treatment facilities must be clearly marked so that the average patron
recognizes them as medical aid stations
On-site treatment facilities must have a clearly marked entrance(s) and exit(s)
consistent with jurisdictional fire codes
Desirable
The location of on-site treatment facilities and/or the procedure to access emergency
medical care should be announced or displayed on a regular basis so that patrons are
aware of this information
Logistics (Location, Hours of Operation, Security etc.)
Essential
On-site treatment facilities must be located in an area that is secure and easily
accessible by the public
The Event EMS Coordinator must ensure the ongoing security of on-site treatment
facilities for equipment, staff and patients
On-site treatment facilities must be operational for the duration of the mass gathering
event, unless the Event EMS Coordinator redeploys staff and equipment
Desirable
The location of on-site treatment facilities should be decided prior to the mass
gathering event
Medical personnel working at on-site treatment facilities should be aware of the
location of the closest security or law enforcement personnel
On-site treatment facilities should be prepared to receive patients one-half hour prior
to the beginning of the event and one-half hour after the conclusion of the event
Off-Site Treatment Facilities
Receiving Hospitals
Essential
One or more receiving hospitals must be designated to receive potential patients from
the mass gathering event
Potential receiving hospitals must be notified of the event prior to its occurrence
The Event EMS Coordinator must ensure that event EMS personnel familiar with
local hospital capabilities assigns transportation destinations to departing ambulances
Desirable
All attempts should be made to appropriately and efficiently distribute casualties to
multiple hospitals in order to prevent “overload”
Distribution of casualties is most effective when planned by the Event EMS
Coordinator in conjunction with local emergency department directors prior to the
event
Hospital Capabilities
Essential
The Event EMS Coordinator must be aware of receiving hospital capabilities and the
availability of specialty services
The closest trauma center to the event location must be identified and its capabilities
categorized prior to the mass gathering event
A mechanism must be in place to alert the Event EMS Coordinator and/or the
Command Post of changes in hospital closure and diversion status
Desirable
Designated pediatric, obstetrical and psychiatric referral hospitals should be identified
prior to the mass gathering event
A designated receiving hospital for contaminated patients from a hazardous materials
or WMD incident should be identified prior to the mass gathering event
TRANSPORTATION RESOURCES
The transportation component of a mass gathering medical action plan defines
how emergency and non-emergency transportation resources will be deployed and
utilized during a mass gathering event. Ground transportation resources are used to
deliver EMS personnel and supplies to the scene of a medical incident and to transport
acutely ill and injured patients to on-site and off-site treatment facilities. Air medical
transportation resources can be used for a variety of purposes: to transport acutely ill and
injured patients to off-site acute care facilities; to deliver additional personnel and/or
equipment to remote venue sites; and to deliver additional personnel and/or equipment
during a mass casualty or disaster incident. Non-emergency transportation resources can
be used to transport patients with minor injuries and/or illnesses to on-site and off-site
treatment facilities and to deliver EMS personnel and supplies to locations within the
mass gathering venue. There are many theories governing the staging of transportation
resources. However these resources are positioned, the following objectives should be
met: response time to medical emergencies should be minimized; access to patient
loading areas should be unimpeded (relatively) and safe; and egress pathways to a
treatment facility should be unimpeded (relatively) and safe.
Transportation Plan
Essential
A basic transportation plan must exist for every mass gathering event
Such a plan must contain at a minimum the number and medical capability (BLS vs
ALS) of ambulances deployed, type and number of non-emergency transport
vehicles, and staging locations for all transportation resources
Such a plan must address how and where additional transportation resources will be
obtained if needed (mutual aid)
Desirable
The transportation plan should predict utilization of transportation resources based on
previous event statistics, if available, and analysis of elements related to patient
generation
Non-emergency transportation resources should be utilized for patients with non-life
and non-limb threatening illness and/or injuries
The number of transportation resources available for event deployment should be
greater than the predicted utilization
The number of on-site ground transportation resources should be maintained at a
constant level
Staging of vehicles should also address refueling and restocking
Dedicated transportation resources should not leave the venue to answer jurisdictional
emergency calls unrelated to the mass gathering event
Emergency Transportation—Ground
Traditional (Ambulance)
Essential
Traditional ground transportation resources must be readily available to respond to
medical incidents at a mass gathering event
Traditional ground transportation resources must be clearly marked and highly visible
Traditional ground transportation resources should meet all state regulations and
licensure standards
Desirable
Traditional ground transportation resources should be dedicated to the mass gathering
event
Traditional ground transportation resources should be on-site at the mass gathering
event
Non-traditional (Modified golf cart, boat or other unusual emergency vehicle)
Essential
Protocols for the appropriate utilization of non-traditional ground transportation
resources, when applicable, must be formulated prior to the mass gathering event
Desirable
Non-traditional transportation resources are usually smaller than traditional vehicles
and should be utilized whenever possible due to their ability to penetrate crowds
Non- traditional transportation resources should be dedicated to the medical sector for
the duration of the mass gathering event, if possible
Non- traditional transportation resources should be clearly marked and highly visible
Non- traditional transportation resources should be staffed by at least one person with
medical training, preferably to the EMT-B level
Emergency Transportation—Air medical
Essential
Protocols for the appropriate utilization of air medical resources must be formulated
prior to the mass gathering event
A dedicated landing zone must be established and secured if air medical resources are
used during a mass gathering event
Desirable
Guidelines for use of air medical resources should be disseminated to EMS personnel
prior to the mass gathering event
Local SOP should be followed concerning fire suppression capability at the landing
zone
Local SOP should be followed concerning security at the landing zone
Non-emergency Transportation
Essential
Protocols for the appropriate utilization of non-emergency transportation resources
must be formulated prior to the mass gathering event
Desirable
Non-emergency transportation resources are highly desirable to reduce utilization of
emergency transportation resources, especially if these are in short supply
Non-emergency transportation resources should be dedicated to the medical sector for
the duration of the mass gathering event, if possible
Non-emergency transportation resources should be clearly marked and highly visible
Non-emergency transportation resources should be staffed by at least one person with
medical training, preferably to the EMT-B level
Staging/Placement of Transportation Resources
Essential
Transportation resources must be geographically staged for a mass gathering event so
that predicted transport times from on-site medical incidents is minimized
Desirable
Emergency transportation resources should be staged on site at a mass gathering
event whenever possible
Designated reserved parking areas should be established for emergency vehicles
Provisions should be made for refueling and restocking of transportation vehicles
PUBLIC HEALTH ELEMENTS
The purpose of the public health component of the medical action plan is to
protect the health and well-being of participants and spectators at a mass gathering event
from infections and unintentional injuries related to improper food, water, waste, land
and/or road/traffic management. Event EMS personnel must determine if the
jurisdictional public health department and other regulatory authorities will be
responsible for oversight of public health concerns at a mass gathering event. While event
EMS personnel may not be directly responsible for any of these areas, a working
knowledge of factors contributing to the development of diseases and injuries related to
improper management of these areas may help reduce the number of medical incidents
during the event.
Definitions for each category are listed below:
Food management includes, but is not limited to, food storage, food handling, food
preparation and the cleanliness, actions and activities of food service personnel.
Water management includes, but is not limited to, resources, supply, distribution,
storage, handling, contents and the devices used to deliver water to the public.
Waste management includes, but is not limited to, water and non-water carried
sewage and their respective disposal facilities, solid, liquid and gaseous wastes, refuse
storage, and refuse disposal.
Land management includes, but is not limited to, flora control, fauna control,
necessary and proper illumination, and appropriate maintenance of terrain integrity.
Road management includes, but is not limited to, maintenance of the following
components: primary and secondary roadways, improved and unimproved surfaces,
necessary and proper illumination, necessary and proper signage, and appropriate
ingress and egress routes for pedestrian and vehicle traffic.
Public Health Element Plan
Essential
A basic plan that addresses the preceding public health elements and the potential for
development of illness and/or injuries due to unforeseen circumstances at mass
gatherings must exist
If the event medical sector has responsibility for one or more of these categories, the
public health component of the medical action plan must include at least a brief
description of the protocols governing these responsibilities and strategies targeted to
handle possible threats
Desirable
A designated medical sector representative should work together with jurisdictional
public health personnel prior to the event to identify potential problems and formulate
potential solutions
A point-of-contact should be identified at the appropriate jurisdictional public health
department prior to the mass gathering event if a public health presence will not be
on-site
Food Management
Essential
Event EMS planners must acquire a basic working knowledge of anticipated food
service operations and food management concerns prior to the event
Event EMS planners must determine prior to the event whether responsibility for food
management and safety has been delegated to the medical sector
If oversight of food management and safety is delegated to the medical sector, the
Event EMS Coordinator should seek consultation from the appropriate jurisdictional
health department concerning basic responsibilities and statutory regulations
Desirable
EMS supervisory personnel should develop a basic understanding of the
epidemiology of food-borne illness
EMS supervisory personnel should understand the principles of preventing food-
borne illness
EMS personnel should be proactive in the prevention of food-borne illness by
observing food handling practices at mass gathering events
Water Management
Essential
Event EMS planners must acquire a basic working knowledge of the venue’s potable
and non-potable water supply and the associated health concerns
Event EMS planners must determine prior to the event whether water-borne health
incidents will be the responsibility of the medical sector
If oversight of water management and/or water supply is delegated to the medical
sector, the Event EMS Coordinator should seek consultation from the appropriate
jurisdictional water authority and health department concerning relevant statutory
regulations
Desirable
EMS supervisory personnel should understand the epidemiology of water-borne
illness
EMS supervisory personnel should understand the principles of preventing water-
borne illness
EMS personnel should be proactive in the prevention of water-borne illness by
observing water management and water supply practices at mass gathering events
Waste Management
Essential
Event EMS planners must acquire a basic working knowledge of waste management
operations and concerns prior to the event
Event EMS planners must determine prior to the event whether waste-borne health
incidents will be the responsibility of the medical sector
If oversight of waste management is delegated to the medical sector, the Event EMS
Coordinator should seek consultation from the appropriate jurisdictional health
department concerning relevant statutory regulations
Desirable
EMS supervisory personnel should understand the epidemiology of infectious illness
related to improper handling of garbage
EMS supervisory personnel should understand the principles of preventing waste-
borne illnesses
EMS personnel should be proactive in the prevention of illness related to improper
handling of garbage by observing waste management practices at a mass gathering
event
Land Management
Essential
Event EMS planners must acquire a basic working knowledge of land management
operations and concerns prior to the event
Event EMS planners must determine prior to the event whether land management and
related public health issues are the responsibility of the medical sector
If oversight of land management is delegated to the medical sector, the Event EMS
Coordinator should seek consultation from the appropriate jurisdictional health
department concerning relevant statutory regulations
Desirable
EMS supervisory personnel should understand the epidemiology of flora- and fauna-
related injury
EMS supervisory personnel should understand the principles of preventing flora- and
fauna-related injuries
EMS personnel should be proactive in the prevention of illness and injuries related to
poor groundskeeping by observing land management practices at a mass gathering
event, if possible
Road/Traffic Management
Essential
Event EMS planners must acquire a basic working knowledge of anticipated food
service operations and concerns prior to the event
Event EMS planners must determine whether road management and related public
health issues are the responsibility of the medical sector prior to the event
If oversight of road/traffic management is delegated to the medical sector, the Event
EMS Coordinator should seek consultation from the appropriate jurisdictional
highway and traffic agencies concerning relevant statutory regulations
Desirable
EMS supervisory personnel should understand the epidemiology of traffic-related
injuries
EMS supervisory personnel should understand the principles of preventing traffic
injuries
EMS personnel should be proactive in the prevention of traffic-related injuries by
observing road/traffic management practices
ACCESS TO CARE
All spectators and participants at a mass gathering event must be able to access
emergency medical care in a timely fashion. The burden of responsibility falls on the
event emergency medical sector to minimize the time interval for victims to correctly
identify the location of medical personnel and/or activate the event EMS system. The
purpose of the access to care component of the medical action plan is to define methods
that patients may use to access emergency medical care at mass gathering events and to
minimize barriers to access for all persons.
Access to Care Plan
Essential
A basic access to care plan must exist for every mass gathering event
Such a plan must address how the venue administration and the medical sector will
inform the public of the location(s) and easiest access to medical care through use of
audio and/or visual aides
Such a plan must ensure compliance with all Americans with Disability Act (ADA)
statutes and with pertinent local, regional and state guidelines
Such a plan must address the strategic location of EMS resources to minimize the
distance and time interval necessary for the patient to reach medical care or vice versa
Desirable
Such a plan should acknowledge the potential barriers to access which cannot be
overcome during the mass gathering event
Such a plan should examine potential barriers to resources which may indirectly lead
someone to become a patient, including but not limited to, water, food, bathrooms
and shelter
Access to Care: Public Education
Essential
All spectators and participants at a mass gathering event must be informed about
accessibility to emergency medical care
The special needs of physically and mentally disabled persons must be included in
plans to access emergency medical care
All emergency medical providers and treatment facilities must be easily identifiable
EMS personnel must wear elements of a uniform identifying themselves as medical
providers or a highly visible cap or command-style vest which is recognizable to the
public-at-large
EMS treatment facilities must be identified by visual aids, such as signs, flags or
posters
Brochures distributed by the venue sponsor should highlight how the public can
access emergency medical care
Desirable
Public address systems should be utilized to announce instructions to spectators about
accessing emergency medical care both at the beginning of the event and at
reasonable intervals
Venue administrators should ensure that event participants are aware of emergency
medical care presence and location
Children under the age of 8 years should be provided identification bracelets upon
entry to the event
EMERGENCY MEDICAL OPERATIONS
The emergency medical operations component of the medical action plan
addresses key operational details central to successful delivery of emergency medical
care not otherwise covered in the document. Although emergency medical operations are
detail-oriented by nature, many of the items listed here are essential to a well-planned
event.
The Event EMS Coordinator is responsible for the creation and the execution of
the operations plan. He/she must ensure that the overall emergency medical operation has
a carefully defined mission and objectives. The mission, its charter, scope, and duration
should be written on official venue stationary (or an equivalent) and be presented to event
administration well ahead of the mass gathering event. This includes procurement of
necessary resources to accomplish tasks listed throughout the document. The medical
sector must also establish a relationship and lines of communication with major factions
at the mass gathering event, including other public safety services.
Finally, the Event EMS Coordinator must be prepared for the possibility of
unusual circumstances, such as care of the VIP patient, standard mass casualty incidents
and a multitude of disaster scenarios, which now include the real possibility of terrorism
and nuclear/biological/chemical attack. There are no expectations that a complex
terrorism response plan will be created for every event solely by the medical sector.
However, it remains the responsibility of the Event EMS Coordinator to participate in
multi-agency planning for such scenarios and to educate all EMS personnel about the
risks and initial response to these occurrences.
Emergency Medical Operations Plan
Essential
A basic emergency medical operations plan must exist for every mass gathering event
Such a plan must address elements of responsibility for medical care, including but
not limited to, contractual relationships, scope of medical care to be provided,
anticipated duration of medical operations and geographic limits of medical coverage
(See Negotiations for Event Medical Services)
Such a plan must address procurement of necessary human and materials resources
for emergency medical operations (See Human Resources and Medical Equipment)
Such a plan must address the relationship of the medical sector to other functional
areas, including but not limited to, fire suppression, security, venue administration,
and venue logistics (See Communications, Command and Control and Public Health)
Such a plan must address financial issues, including but not limited to, overall budget,
procurement, and human resource compensation
Such a plan must address how medical care for celebrities, VIPs and/or high-ranking
government figures will be handled
Such a plan must address existing mutual aid plans and the procedure for activation of
this system
Such a plan must address mass casualty incident and disaster planning
Such a plan must address an initial response to an act of terrorism, including the use
of weapons of mass destruction or other hazardous materials
Desirable
The Event EMS Coordinator should craft a mission statement and main objectives for
the delivery of emergency medical care at the mass gathering event, including non-
traditional elements, such as public health, if applicable
EMS personnel should be familiar with this mission statement and should strive to
uphold it
Such a plan should address the relationship of the medical sector to other functional
areas, including but not limited to, non-medical transportation, event sponsors, public
relations, and non-medical human resources
Operational Details of Medical Care
Essential
The Event EMS Coordinator must have clear authority via a contractual relationship
to supervise the delivery of emergency medical care at the mass gathering event
If more than one agency is involved in the delivery of emergency medical care, a
chain of command and responsibility must be established prior to the mass gathering
event
The scope of emergency medical care to be delivered must be clearly defined and
agreed upon by event administration and the Event EMS Coordinator prior to the
mass gathering event
The duration of delivery of emergency medical care must be clearly defined and
agreed upon by event administration and the Event EMS Coordinator prior to the
mass gathering event
The geographic coverage area for emergency medical care must be clearly defined
and agreed upon by event administration and the Event EMS Coordinator prior to the
mass gathering event
Desirable
The scope of emergency medical care to be provided depends not only on what is
considered the standard, but also the reality of what resources are available
EMS personnel should not be responsible for responding to emergency calls outside
the defined event coverage area, but should notify the appropriate jurisdictional EMS
provider
EMS personnel should generally be on-site at a mass gathering event one hour prior
to the start of the event and one hour after the event concludes
Relationship to Other Venue Disciplines
Essential
The Event EMS Coordinator must establish a working relationship with venue
owners and event administration
The Event EMS Coordinator must establish a working relationship with venue
logistics
The Event EMS Coordinator must establish a working relationship with security and
law enforcement officials
The Event EMS Coordinator must establish a working relationship with fire
suppression and other public safety services
The Event EMS Coordinator must establish a working relationship with the
jurisdictional public health director
Desirable
The Event EMS Coordinator should establish a working relationship with public
relations
The Event EMS Coordinator should establish a working relationship with non-
medical transportation and non-medical human resources
The Event EMS Coordinator should establish a working relationship with event
sponsors
The Event EMS Coordinator should assist and promote the establishment of a
working relationship between law enforcement/security agencies and the
jurisdictional public health director
The Event EMS Coordinator should attempt to establish a relationship with medical
equipment manufacturers, including those that supply prehospital equipment, for the
purposes of securing donations or loans of equipment
Financial Issues
Essential
The Event EMS Coordinator and the event director (administrator) must jointly
calculate an overall budget for the delivery of emergency medical care at a mass
gathering event
Such a budget must include costs related to the procurement and deployment of
medical supplies, transportation resources, human resources and on-site treatment
facilities, if applicable
The Event EMS Coordinator must address the issue of human resource compensation,
including, but not limited to, legal ramifications, ethical ramifications, source of
payment and monetary versus non-monetary compensation
Desirable
Event sponsors should be responsible for as much of the reasonable costs related to
delivery of emergency medical care as possible
EMS personnel should receive some form of compensation for their work
The Event EMS Coordinator should seek donations to help offset the costs of delivery
of emergency medical care if this care is being delivered by volunteers and/or non-
profit organizations
VIP Care and Dignitary Protection
Essential
The Event EMS Coordinator must ascertain whether there is a reasonable possibility
that any VIP, celebrity, dignitary or high-ranking government official will attend the
mass gathering event
The Event EMS Coordinator must work jointly with event administration, law
enforcement and other security and venue personnel to develop contingency plans for
VIPs and dignitaries who may become ill or injured at the mass gathering event
The Event EMS Coordinator must work jointly with event administration, law
enforcement and other security and venue personnel to ensure that operational details
and VIP/dignitary security concerns do not adversely impact the health of the general
public at a mass gathering event
Desirable
A separate treatment area should be designated for VIPs and dignitaries both to
protect their privacy and to avoid crowd hysteria and interference with patient care
The Event EMS Coordinator should attempt to secure pertinent background medical
information on any VIPs and/or dignitaries who may be in attendance at the mass
gathering event
The Event EMS Coordinator should designate a treatment team for VIPs and/or
dignitaries composed of the minimum number of personnel properly trained and
equipped to handle both routine and life-threatening emergencies
Mutual Aid
Essential
The Event EMS Coordinator must collaborate with the jurisdictional EMS providers
to ensure that a realistic mutual aid plan exists for the mass gathering event
Desirable
Mutual aid units should be aware of the mass gathering event and the possibility that
their services may be requested
Mutual aid services should receive maps of the venue site indicating access routes
and locations of on-site treatment facilities
Mass Casualty Incident (MCI) and Disaster Planning
Essential
The Event EMS Coordinator must plan for the possibility of an MCI or disaster event
during the mass gathering
Such planning should specifically address the two most likely types of disasters at
mass gatherings, environmental (weather) disasters and technological disasters
EMS personnel must be aware of SOPs regarding disaster operations, including
medical protocols and other operational guidelines
All medical personnel must be assigned MCI roles prior to the beginning of the event
MCI roles should be based upon the local fire department MCI plan or an accepted
incident management system
Desirable
An MCI/disaster trailer should be on-site or immediately available for large scale
mass gathering events and those in which it is predicted that patient volume will be
excessive
Triage tags should be uniform in design and centrally located at the venue site if not
already carried by all field EMS personnel
Hazardous Materials and Weapons of Mass Destruction Response
Essential
The Event EMS Coordinator must have completed a Hazardous Materials Awareness
course within the last three years
EMS personnel must be briefed about potential hazardous materials that exist at or
near the venue site
The Event EMS Coordinator must maintain close contact with security officials so
that he/she may be alerted to any possibility or threat of terrorism as early as possible
Desirable
The Event EMS Coordinator should have additional hazardous materials experience
or training to the Hazardous Materials Operations level
The Event EMS Coordinator should have completed a course in medical aspects of
terrorism within the last three years
Hazardous Materials mitigation capability should be on-site or immediately available
for high profile mass gathering events and those in which threats have been received
The Event EMS Coordinator should give serious consideration to distribution of gas
masks and Mark I kits to all EMS personnel at major mass gathering events,
especially those in large cities, those that draw VIPs and government officials, and
those that law enforcement experts consider to be at high risk for terrorist attack
COMMUNICATIONS
Efficient information flow is vital to the successful delivery of emergency
medical care at a mass gathering event. Information flow is reliant upon a
communications system, which utilizes communications hardware and protocols to link
patients with patient care providers through a centralized hub, or command post. (For a
discussion of command post issues, see the Command and Control section.) The
communications component of a medical action plan defines how information pertinent
to medical care and medical issues is managed and disseminated during the mass
gathering event and how the communications system is designed and operated. Since a
properly functioning communications system is absolutely necessary for the delivery of
emergency medical care, the Event EMS Coordinator must participate in the design and
testing of the system to ensure its effectiveness and reliability.
Communications hardware may include a base station and portable radios,
scanners, repeaters and transmission equipment. The exact configuration of the system,
including type and number of radios needed, will be unique to each event and may
largely depend on how the local public safety system is currently functioning. Vendors
may need to be contacted to supply additional radios or to lease frequencies for larger
events and/or those in which there is inadequate communications coverage.
A variety of communication links must be established during a mass gathering
event. Event organizers may need to communicate important and time-sensitive
information to medical personnel and vice versa. Such links are necessary between the
command post and EMS personnel, transportation vehicles, acute care facilities and the
local public safety answering point (PSAP).
Communications Plan
Essential
A basic medical communications plan must exist for every mass gathering event
Such a plan must address number, type and sophistication of equipment necessary
and available
Such a plan must include the designated radio frequencies and phone numbers of
supervisory medical personnel
Such a plan must be reviewed and approved by local officials to ensure that it does
not interfere with communications protocols of local emergency services
Such a plan must identify the command post by an acronym (i.e. “Medical
Command”) and authorize its function as the lead communications entity for the mass
gathering event
A system of communications must be designed to ensure that non-medical personnel,
such as ushers, can alert medical personnel to the presence of a medical emergency
Communications protocols must be designed for use by all personnel equipped with
radios
All communications protocols should include rules of etiquette which maximize
efficiency and minimize interference of vital transmissions
Communications protocols must be reviewed with all medical personnel prior to the
event
Desirable
Radio designations should be allocated to EMS command personnel and
transportation resources to enable easy identification
Redundant communications technology should be utilized to avoid system failure
Equipment
Essential
A dedicated medical communications system must exist for the mass gathering event
Sufficient support equipment must be available to prevent communications failures
Desirable
EMS personnel should be involved in the design of a medical communications system
and acquisition of necessary communications equipment
Communications equipment should be tested prior to the mass gathering event to
ensure effectiveness
Speaker microphones should be available for EMS personnel roaming on foot or in
crowds
Headsets should be available for EMS personnel who are operating in loud
environments
Personnel
Essential
The Event EMS Director must designate a communications manager for the event
The Event EMS Director or a designated communications manager must ensure that
the following actions are accomplished prior to the event:
o Procure, test and distribute all radio equipment
o Procure, test and maintain radio and/or battery chargers
o Construct, test and maintain on-site landline and/or cellular phone connections
o Ensure functional communication links (see below)
Communications Links
Essential
The command post (“Medical Command”) must be able to communicate with the
following resources and medical personnel by radio, cellular phone or landline:
Event administrators (Security, Maintenance, public address announcer)
All EMS command personnel
Intravenue EMS personnel (roving)
Intravenue EMS personnel at fixed medical facilities
Transportation resources, including ambulances dedicated to the event
Non-medical personnel assisting with medical reconnaissance (“spotters”)
Public safety answering point (PSAP) and emergency operations center (EOC) for
the jurisdiction in which the event is being held
Director of the multiple casualty incident (MCI) plan for the jurisdiction
Director of public health for the jurisdiction
Acute care facilities and emergency departments to which patients are likely to be
transported (includes ED Directors)
Medical direction resources
Desirable
Communications capability should exist between EMS providers and EMS
transportation resources at the venue
Communications capability to transportation resources should not be compromised
when they are off-site (relative to effectiveness of radio transmission)
COMMAND and CONTROL
The purpose of the command and control component of a medical action plan is to
formulate an organizational structure that guides the provision of emergency medical care
at a mass gathering event. This section of the plan must show clear lines of authority and
responsibility for each medical position. It must also delineate the integration of medical
oversight into the overall administrative structure of the event. It is suggested that the
Incident Command System be utilized for this purpose.
At the heart of every mass gathering command and control plan is the command
post, which functions as a centralized hub for command and control, communications and
dissemination of information. It can be as simple as an individual sitting at a table or as
sophisticated as a dedicated custom-built emergency vehicle. Regardless of the physical
make-up, the command post must serve as the lead medical command and
communications entity and the focal point for information relay.
Every mass gathering event must have a functional Coordinator of EMS
Operations. With the exception of the Event EMS Medical Director, who must be
appointed for every event, the exact number and type of other EMS administrative and
operational positions will largely depend on local preference and needs. It is highly
desirable that any individuals involved in planning for this type of event medical
coverage have experience and/or formal training in the process.
Command and Control Plan
Essential
A basic command and control plan must exist for every mass gathering event
The command and control plan must designate essential EMS administrative
personnel for the event
The command and control plan must designate essential EMS operations personnel
for the event
The command and control plan must include an organizational chart with a list of job
assignments/tasks for each position, the number of personnel filling each position and
a reporting structure
The command and control plan must outline a system of medical oversight
Desirable
Command and control assignments and structure should follow the Incident
Command System
When the mass gathering event involves multiple public safety services or EMS
systems, the unified command model should be invoked
Command Post
Essential
The location of the command post and its contact telephone number(s) and/or radio
identifier(s) must be clearly and rapidly identifiable to all EMS personnel
The command post must be staffed continuously from a predesignated time prior to
the event to a predesignated time following the event
The command post must be staffed by at least one individual at all times
The administrative and medical functions within the command post must be separate
from other operations if a unified command post concept is in place
Desirable
The command post should be clearly marked and highly visible
The command post should remain in a fixed location, if possible
The command post should be a physical entity, rather than an individual, if possible
The command post should be located in proximity to that of the following services:
Event administration
Security
Venue maintenance
Public affairs and public address announcer
The Command Post should maintain and update important information, such as acute
care facility closure and diversion status, during events that are capable of generating
large volumes of patients
EMS Administrative Positions
Essential
An Event EMS Coordinator must be appointed for every mass gathering event
The Event EMS Coordinator must be a certified/licensed EMS provider in the state in
which the event is being held
Desirable
The Event EMS Coordinator should have previous mass gathering medical care
experience
Other EMS administrative positions may need to be designated based on event
characteristics or local EMS practices
EMS Operations Positions
Essential
A designated EMS supervisor must be appointed for every mass gathering event
A designated EMS supervisor must be on-site for every mass gathering event
Desirable
The Event EMS Coordinator or his/her designee should be on-site for every mass
gathering event
Other EMS Operations positions may need to be designated based on the event or
local EMS practices
DOCUMENTATION
The purpose of the medical documentation component of the medical action plan
is to ensure a uniform approach to record keeping. The patient care record is a legal as
well as a medical document. There is a preponderance of anecdotal evidence to support a
claim that medical record keeping at many mass gathering events is less than satisfactory
for a variety of reasons, including overwhelmed medical staff and lack of a clear strategy
for medical documentation. There is also evidence that medical record keeping may be
disorganized and nonstandard at many mass gathering events. Thus, various medical
providers may record chief complaints and diagnoses differently, or not at all. This is a
dangerous practice from a legal standpoint. It also precludes proper evaluation and
interpretation of statistics that may help to drive a more objective approach to planning
for medical needs at future mass gathering events of similar nature.
The cornerstone of a documentation plan is the patient care report. Such a report
is essential to record patient complaint and treatments rendered. Exactly who is a patient
must be determined prior to the event. The style and complexity of mass gathering
medical care documentation is highly variable around the country but must conform both
to local/state regulations and to general medicolegal principles. All patient contacts must
be documented in some form, preferably one that is consistent throughout the venue.
Special circumstances, such as the unaccompanied minor, the patient with minor
complaints or needs and the patient who refuses care or leaves the medical sector prior to
the completion of treatment, must be addressed from a documentation standpoint as well
as a medicolegal one.
Documentation Plan
Essential
A basic medical documentation plan must exist for every mass gathering event
Such a plan must address how patient contacts will be recorded
Such a plan must address the type, complexity and methodology of patient care
documentation
Such a plan must address how patient care documentation will be collected and stored
following the conclusion of the mass gathering event
All local, regional and state regulations regarding medical documentation must be
followed
Desirable
A unique event patient care form should be developed prior to the event
If a unique event patient care form is not developed, the local EMS patient care
record should be utilized for every patient contact
Accurate records should be kept concerning response times for patient retrieval,
transport times to definitive care, supplies utilized, major decision-making and its
outcome, and any problems encountered
A uniform approach to the categorization and documentation of patient complaints
should be designed prior to the event
EMS personnel should be educated prior to the event regarding the preferred method
of documentation and standardization of patient records
Consider delegating the duties of scribe to ancillary personnel assigned to on-site
treatment facilities
Patient Care Documentation
Essential
All patient contacts must be documented
Minimal essential elements for patient documentation include basic demographic
information, location of incident, chief complaint, focused history and physical exam,
treatment and final disposition
Documentation must be recorded for all patients who refuse treatment or leave prior
to completion of treatment, often referred to as Refusal of Medical Aid (RMA) or
Against Medical Advice (AMA)
Desirable
A “patient contact” should be defined prior to the mass gathering event
Any person who receives medical care, advice or supplies from a medical
professional at a mass gathering event should be considered a patient
Notation should be made about whether or not parents could be contacted whenever
minors present as patients
Notation should be made for patients who present more than once for emergency
medical treatment, especially for similar complaints
Receiving hospitals should be provided with a copy of the patient care
documentation, if possible
Patients who refuse care or sign out of the medical sector against medical advice
should be informed of the risks of doing so and should sign a statement attesting to
their actions
When treatment facilities become overwhelmed by patients, a request for assistance
with documentation should be placed to the Command Post
CONTINUOUS QUALITY IMPROVEMENT
The purpose of the continuous quality improvement component of the medical
action plan is to ensure that the delivery of mass gathering medical care is constantly
improving through analysis of medical sector performance. This can be accomplished in
several ways, including patient care report review, structured critique of the incident and
review of notes and other data relating to EMS system performance at the mass gathering
event. A proactive medical CQI plan is an important element of risk management for the
event administration and venue owner.
Continuous Quality Improvement Plan
Essential
A basic CQI plan must exist for every mass gathering event
Such a plan must address how information on the delivery of mass gathering medical
care at this event will be used to improve medical care and planning for future events
of a similar nature
Such a plan must address how event data will be collected
Such a plan must delineate who is responsible for “real time” event data collection
The definition of a patient encounter for paperwork purposes must be made prior to
the event
Desirable
An event debriefing should be held within a reasonable timeframe after the
conclusion of the mass gathering event
Such a debriefing should be structured in a positive fashion so that it emphasizes
education and improvement
A list of recommendations and conclusions regarding mass gathering medical care
should be generated and distributed to all parties concerned within a reasonable
timeframe after the conclusion of the mass gathering event
Event Data Collection and Analysis
Essential
The Event EMS Coordinator must ensure that basic facts and figures concerning the
delivery of medical care and patient volume at the event are recorded and/or obtained
for appropriate analysis
A medical record form must be generated for every patient encounter
A confidential medical record form designed and approved under the guidance of the
Event EMS Coordinator and Event EMS Medical Director must include the following
items:
o Encounter date
o Encounter time
o Patient name
o Patient sex
o Patient age
o Chief complaint
o Pertinent medical history
o Drug allergies
o Pertinent physical exam findings
o Diagnostic impression
o Treatment
o Disposition
Desirable
Event data analysis should be undertaken by the Event EMS Coordinator or his/her
designee within a reasonable timeframe after the conclusion of the mass gathering
event
Selected patient care reports including incidents of critical illness and non-transports
should be reviewed by the Event EMS Coordinator or his/her designee within a
reasonable timeframe after the conclusion of the mass gathering event
EMS supervisory personnel on-site should be encouraged to record ongoing notes
concerning medical sector performance
Venue administration should be encouraged to supply necessary information/statistics

Supplementary resource (1)

... The logistics section of the commission gave priority to health issues six months prior, thereby seeking to provide efficient care and enabling volunteer participation. At this time, three specialized subcommittees were created to organize respective components after reviewing all available evidence (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) actions to be completed in a coordinated, efficient, and effective manner. The health of the Pope and his retinue was then commissioned to an independent medical team. ...
Preprint
Full-text available
There is a lack of information in the current literature concerning the nature of prehospital care at mass-gathering religious events. However, significant effort is required to conduct medical planning for these massive events, where numerous patients with different comorbidities and presentation symptoms must be attended both duly and efficiently. Medical staff should also be prepared for code black (bomb threat) warnings and must stratify and transfer the most critical cases based on their triage scores. This study examined the development of a model capable of complying with these requirements, thus allowing staff to solve most medical cases in situ while transferring only the most severe. After reviewing related literature in the Chilean context and considering local epidemiological concerns, resources, and necessities, this study reviewed a high-resolution staggered pre-hospital care model for mass-gathering events that was developed to provide proper and effective attention to all patients during Pope Francis's 2018 visit. The model implemented a severity-based algorithm for the in situ transference of patients and a staggered strategy of attention. A total of 400,000 people attended the event, the setting of which was divided into 17 plots with 17 primary, three intermediate, and one advanced tents. Further, there were 16 ambulances, 92 physicians, 51 nurses, and 222 paramedics available to attend patients with the help of 28 medical and 34 nursing students. A total of 414 instances of service were delivered, with a Patient Presentation Rate of 10.35 per 10,000 attendees and a Transfer to Hospital Rate of 0.2. No patients died during the event. The model thus facilitated staff in giving proper and efficient attention to all patients, thereby providing a useful tool that can be implemented at future events.
... As regards the specific category of religious MGs contagious diseases are still the main health hazard [9]; however these crowding events also constitute an attractive target for terrorists because of some specific reasons [10]: ...
Article
Full-text available
Mass gatherings are unique events carrying the potential to severely strain public health planning and infrastructures by triggering the entire emergency mechanism of a community or nation. That is mostly the case in terrorist attacks, an overwhelming, though not the most common health-related hazard in mass gatherings. The implementation of a protective mechanism against such threats is pronouncedly cumbersome and requires a complex administrative strategy, detailed operational planning and also a deep interoperability of the major health and homeland security stakeholders. That can be accomplished with an Incident Command System that affords organizational guidelines and flexible tactical planning, which refer to actions undertaken before, during and after the incident. The main challenges before the health incident are named preparedness, surveillance, incident action plans, environmental health/food safety and personnel training; the objectives to be achieved during the main phase of the incident are communication, response, dispensing planning and interoperability. Of the post-incident phase, the most important objectives are the mental first aid provision and the transparent key-messages of post hazard communication.
... As regards the specific category of religious MGs contagious diseases are still the main health hazard [9]; however these crowding events also constitute an attractive target for terrorists because of some specific reasons [10]: ...
Article
Mass gatherings are unique events carrying the potential to severely strain public health planning and infrastructures by triggering the entire emergency mechanism of a community or nation. That is mostly the case in terrorist attacks, an overwhelming, though not the most common health-related hazard in mass gatherings. The implementation of a protective mechanism against such threats is pronouncedly cumbersome and requires a complex administrative strategy, detailed operational planning and also a deep interoperability of the major health and homeland security stakeholders. That can be accomplished with an Incident Command System that affords organizational guidelines and flexible tactical planning, which refer to actions undertaken before, during and after the incident. The main challenges before the health incident are named preparedness, surveillance, incident action plans, environmental health/food safety and personnel training; the objectives to be achieved during the main phase of the incident are communication, response, dispensing planning and interoperability. Of the post-incident phase, the most important objectives are the mental first aid provision and the transparent key-messages of post hazard communication.
Article
Objective: Vertical running events, during which participants race up the stairwells of skyscrapers, are becoming increasingly popular. Such events have unique and specific operational and clinical considerations for event medical directors, but descriptions of the medical care provided at these events are lacking. We sought to perform a descriptive analysis of the medical care delivered at a single, large vertical running event. Methods: A retrospective chart review of medical encounters at a large vertical running event from 2011-2017 was performed. Participants competed in either the full course (94 stories) or half course (54 stories); potential patients also included observers. Medical staffing included a main medical station at the finish line, medical way stations along the routes (within stairwells), and medical response teams. Descriptive statistics were used for analysis. Results: During the study period, a total of 23,920 participants completed the event, with 84.6% participating in the full course. Medical staff treated 150 unique patients during 154 medical encounters (0.6% treatment rate). The median age of patients was 36 (IQR 27, 43), and 40.3% were male. Most encounters (66.4%) occurred at the finish line main medical area. Of medical encounters occurring along the race routes, 56.1% of encounters occurred before the halfway point in the full course. Encounters were clustered around medical way stations along the half course. The most common chief complaints were gastrointestinal (27.3%), respiratory (25.3%), syncope/near-syncope (24.7%), trauma (12.3%), and chest pain (10.4%). One cardiac arrest was observed. The most frequent interventions were oral fluids or food (40.3%), respiratory care (18.2%), and minor trauma care (12.3%). An electrocardiogram (ECG) was obtained in 10.4% of encounters, and intravenous fluids were started on 1.9% of patients. Eleven patients (7.3% of treated patients and 0.05% of all participants) were transported by ambulance. Conclusions: Medical encounters during vertical running events, the majority of which are not life-threatening, mainly occur at the finish line but can occur at any point along the route. Understanding the nature and location of medical encounters along a vertical running event route can help inform event medical directors supervising care at these increasingly popular events.
Article
Objectives The aim of this study was to examine the various modern music genres and their effect on the utilization of medical resources with analysis and adjustment for potential confounders. Methods A retrospective review of patient logs from an open-air, contemporary amphitheater over a period of 10 years was performed. Variables recorded by the medical personnel for each concert included the attendance, description of the weather, and a patient log in which nature and outcome were recorded. The primary outcomes were associations of genres with the medical usage rate (MUR). Secondary outcomes investigated were the association of confounders and the influences on the level of care provided, the transport rate, and the nature of medical complaint. Results A total of 2,399,864 concert attendees, of which 4,546 patients presented to venue Emergency Medical Services (EMS) during 403 concerts with an average of 11.4 patients (annual range 7.1-17.4) each concert. Of potential confounders, only the heat index ≥90°F (32.2°C) and whether the event was a festival were significant (P=.027 and .001, respectively). After adjustment, the genres with significantly increased MUR in decreasing order were: alternative rock, hip-hop/rap, modern rock, heavy metal/hard rock, and country music (P Conclusion Alternative rock, hip-hop/rap, modern rock, heavy metal/hard rock, and country music concerts had higher levels of medical resource utilization. High heat indices and music festivals also increase the MUR. This information can assist event planners with preparation and resource utilization. Future research should focus on prospective validation of the regression equation. Westrol MS, KoneruS, McIntyreN, Caruso AT, ArshadFH, MerlinMA. Music Genre as a Predictor of Resource Utilization at Outdoor Music Concerts. Prehosp Disaster Med. 2017;32(3):289–296.
Article
Background The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on emergency medical services (EMS) and local EDs. Literature concerning the safety of these events is minimal and mostly consists of media reports. We sought to characterise the injury and illness profile of OCRs and the level of medical care required. Methods This study analysed OCR events occurring in eight locations across Canada from May to August 2015 (total 45 285 participants). Data were extracted from event medical charts of patients presenting to the onsite medical team, including injury or illness type, onsite treatment and disposition. Results There were 557 race participants treated at eight OCR events (1.2% of all participants). There were 609 medical complaints in total. Three quarters of injuries were musculoskeletal in nature. Eighty-nine per cent returned to the event with no need for further medical care. The majority of treatments were completed with first aid and basic medical equipment. Eleven patients (2% of patients) required transfer to hospital by EMS for presentations including fracture, dislocation, head injury, chest pain, fall from height, and abdominal pain. Conclusions We found that 1.2% of race participants presented to onsite medical services. The majority of complaints were minor and musculoskeletal in nature. Only 2% of those treated were transferred to hospital through EMS. This is consistent with other types of mass gathering events.
Article
Organized mass gathering medical care (MGMC) has existed in the United States for 30 years, but there is little evidence to support any standard of care or uniformity in its delivery. To determine whether MGMC regulations exist within state EMS legislation and to describe the characteristics of any such regulations. The authors conducted a cross-sectional survey of U.S. state EMS directors in fall 1998 to determine the prevalence of formal legislation governing MGMC. The lead author received copies of legislation from every state EMS office that indicated such legislation existed. Responses were obtained from all 50 state EMS offices and that of the District of Columbia (n = 51). Only six (12%) states provide regulatory guidance for MGMC. These regulations reside within departments of health in all six states and within the divisions of EMS in three of these six. Only one state requires physician oversight of a medical action plan and minimum staffing by EMS personnel, respectively. No state addresses early defibrillation capability or EMS scope of practice. There is no agreement on the definition of either a mass gathering or minimum resource deployment. Public health and hygiene practices at mass gatherings also lack uniformity. Few states regulate MGMC. Existing regulations are poorly developed and lack both standardized terminology and content.