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Mass gathering medical care

January 2000

Authors:

University of Massachusetts Chan Medical School

• Treatment facilities • Transportation resources • Public health elements • Access to care • Emergency medical operations • Communications • Command and control • Documentation • Continuous quality improve-

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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

NAEMSP Position paper

Data

March 2017

David Jaslow · Arthur Yancy II · Andrew Milsten

Download

Development of a High-Resolution Staggered Prehospital Care Model for Mass-Gathering Religious Events

Preprint

Full-text available

Nov 2019

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.

Health care challenges at mass gatherings

Article

Full-text available

Jan 2021

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.

Health care challenges at mass gatherings

Article

Full-text available

Nov 2020

Mass Gatherings

Chapter

Jan 2024

Human Stampede

Chapter

Jan 2024

Abdullah Ahmed Alhadhira

ICT System for Crowd Management: Hajj as a Case Study

Conference Paper

Sep 2020

Medical Care at a Large Vertical Running Event

Article

Aug 2017

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.

Music Genre as a Predictor of Resource Utilization at Outdoor Music Concerts

Article

Feb 2017

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.

Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)

Article

Sep 2016

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.

Mass Gatherings

Chapter

Dec 2016

Medical care during the November 1969 antiwar demonstrations in Washington, DC. An experience in crowd medicine

Article

Feb 1971
ARCH INTERN MED

Characteristics of state legislation governing medical care at mass gatherings

Article

Oct 1999

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.

Mass gathering medical care

Abstract

Supplementary resource (1)

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