Mass gathering medicine: a review

The provision for emergency medical care for spectators and participants at large events is a growing area of interest. This article describes the definition and characteristics of medical care at mass gatherings. The literature is reviewed with regard to the planning, organization, personnel, and staffing required at these events. The equipment and transportation assets needed are also discussed. Disaster and mass casualty planning implications also are described.     

Mass gathering medicine for the First East Asian Football Championship and the 24th European/South American Cup in Japan.

It is very important to collect and accumulate data of same-type events from the point of view of appropriate preparedness for mass gathering medicine. On the basis of the experience of the 2002 FIFA World Cup Korea/Japan, the Japanese Association of Disaster Medicine organized the emergency medical assistance team during large football events. The objective was to analyze all clinical presentations available to the on-site physicians during this event. The total number of patients was 51 (patient presentation rate: 0.25/1000 spectators). Trauma, abdominal pain and common cold were the main pathologies encountered. Eight patients were transported to hospital. Forty-one patients (80.4% of total) were treated within the medical station and were not transported to hospital. These dispositions were considered to lighten the burden imposed on activities of local emergency medical services. Sharing databases with local medical services and surveying the outcome of patients are needed to allow patient presentation provision.     

On-site physicians at a major sporting event in Nigeria

INTRODUCTION: Although the need for on-site physicians at mass gatherings has been investigated in developed countries, it has not been studied in a developing country, where resources are limited, paramedical services are unavailable, and transportation and other facilities are inadequate. HYPOTHESIS: The presence of on-site physicians would result in the effective management and prehospital care of casualties at mass gatherings or major sporting events in a developing country. METHODS: A retrospective review of the planning procedures and medical records of the 19th Nigerian University games was conducted. Data from demographic profiles of visitors presenting to the on-site, secondary, and tertiary medical centers and the treatments used were extracted from log-books and processed and interpreted. RESULTS: The Games hosted 6000 accredited athletes and officials, and an estimated 80,000 spectators. Medical coverage was provided by 54 doctors and other healthcare staff at on-site, secondary, and tertiary medical centers. No trained paramedics were available. A total of 494 visits were made to the medical centers (medical usage rate of 2.1/1000, patient presentation rate of 0.08). Forty-six percent of the visitors were evaluated by a physician on-site. Ninety percent of the visits were managed on-site, while 5% and 3% were referred to secondary and tertiary medical centers, respectively. CONCLUSION: The presence of on-site physicians at a major sporting event resulted in the majority of injuries and complaints being effectively treated on-scene. This reduced the number of hospital referrals and saved time and money for treatment.     

Mass Gathering Medical Care: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre–event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the community's medical care system, while fulfilling the needs of event participants.     

Medical care for a mass gathering: the Suwa Onbashira Festival

INTRODUCTION: The Suwa Onbashira Festival is held every six years and draws approximately one million spectators from across Japan. Men ride the Onbashira pillars (logs) down steep slopes. At each festival, several people are crushed under the heavy log. During the 2004 festival, for the first time, a medical care system that coordinated a medical team, an emergency medical service, related agencies, and local hospitals was constructed. OBJECTIVE: The aims of this study were to characterize the spectrum of injuries and illness and to evaluate the medical care system of this festival. METHODS: The festival was held 02 April-10 May 2004. The medical records of all of the patients who presented to an on-site medical tent or who were treated at the scene and transported to hospitals over a 12-day period were reviewed. The following items were evaluated: (1) the emergency medical system at the festival; (2) the environmental circumstances; and (3) patient data. RESULTS: All medical usage rates are reported as patients per 10,000 attendees (PPTT). A total 1.8 million spectators attended the festival during the 12-day study period; a total of 237 patients presented to the medical tent (1.32 PPTT), and 63 (27%) were transferred to hospitals (0.35 PPTT). Of the total, 135 (57%) suffered from trauma--two were severely injured with pelvic and cervical spine fractures; and 102 (43%) had medical problems including heat-related illness. CONCLUSIONS: Comprehensive medical care is essential for similar mass gatherings. The appropriate triage of patients can lead to efficient medical coverage.     

Analysis of a medical tent at the Toronto Caribana Parade

Objectives. To review the experience with an on-site medical tent for a mass gathering and to analyze patient records in a manner to more appropriately allocate resources and identify possible delays in definitive care. Methods. The logistics of providing an on-site medical tent is reviewed, followed by a retrospective chart review of 126 patients over a two-year period. Prior to the chart review, an injury classification was developed that categorized patients based on the necessity of transport to hospital. Data were also analyzed for times of peak patient flow, types of injuries, and needless delays in definitive care. Results. An average of 63 patients (95% CI 44-77) were seen in the tent and 1.3 patients sought care per 10,000 spectators. Peak times were between 1600 and 2000 hours. The average number of patients each hour was 6.5 (95% CI 0-13). Severe, intermediate, and minor injuries accounted for 16%, 38%, and 46% of total injuries, respectively. Nine cases were found where the patients arrived and left the medical tent by ambulance. Four of these instances may have represented a needless delay in definitive care. The details of each of these cases are reviewed. Conclusions. The results indicate that on-site medical coverage, with appropriate supports, is indeed safe. The framework provided with regard to setup and analysis of workload will help others in the planning of medical care for similar mass gatherings. PREHOSPITAL EMERGENCY CARE 2002;6:199-203     

Mass gathering medical care: a twenty-five year review

INTRODUCTION: The purpose of this study was to critically review the provision of medical care at mass gatherings as described in 25 years of case reports. Specifically measured was the relationship between the size of a mass gathering and the frequency of patients seeking medical aid and the effects of certain event characteristics on this relationship. METHODS: Data were obtained through a retrospective literature review. Medline and CINHAL computerized databases were searched for English language articles using several keywords: "mass gathering", "concert", "festival", "Olympics", "crowd"; "riot", "stadium", "sports", "games", "papal", and "football". Only articles containing complete information on the number of spectators, number of patients, type, location, and duration of the mass gathering were included in the primary analysis. As available, additional information was added including the described weather patterns, number of patients transported to a hospital, and number of patients suffering a cardiac arrest. Thirty-five of the approximately 100 articles reviewed, met these criteria. RESULTS: A Spearman Rank Correlation Coefficient was calculated for number of spectators and patients and a significant relationship was identified (p = 0.0001). Mann-Whitney U-tests indicated that papal masses (p = 0.04), rock concerts (p = 0.005), hot climatic conditions (p = 0.03), and events held in the British Commonwealth (p = 0.03) had a significantly higher frequency of patient visits. Significantly more cardiac arrests occurred at papal masses (p = 0.04) and sporting events (p = 0.0002). CONCLUSIONS: Type of event, country, weather, and the size of the mass gathering had a significant effect on the numbers of spectators seeking medical care. A uniform classification scheme is necessary for future prospective studies of mass gatherings.     

Hospital-based healthcare provider (nurse and physician) integration into an emergency medical services-managed mass-gathering event

INTRODUCTION: This report describes not only the implementation of a coordinated emergency medical services-hospital-based healthcare team but also investigates the integration of nurse-physician teams at a mass gathering medical care event. METHODS: A review of resource utilization, patient encounters, and local ED census was performed during this period at a college football stadium. RESULTS: During this 4-year period, 1681 patients presented for medical care during 26 events with a total attendance of 1,544,244 (1.09 patients per thousand attendees [PT]). The majority of patient contacts were for minor complaints (1451, 87.6%), whereas 205 (12.4%) received full evaluations (focused history and physical examination most often with pulse oximetric and electrocardiographic monitoring). A total of 109 patients were transported (4.19 PT), representing 6.48% of all patients. Patient census for the event medical deployment increased from 0.44 PT in 2001 to 1.75 PT in 2004. The number and percent of patients transported also increased between 2001 (0.02 PT, 4.48%) and 2004 (0.12 PT, 6.67%). However, 118 (57.6%) patients who received full evaluations were able to be discharged by a physician, avoiding transport. Chief complaints and management of patients receiving full evaluations were consistent across this period, with altered mental status (52.7%) and chest pain (12.7%) as the most common complaints. Average ED census during this period was found to be significantly higher on event days (176.2) than nonevent days (161.2) (t = 8.04, P < .001), although this produced only a minor impact on the emergent care system. CONCLUSION: This study describes one potential deployment plan for a mass gathering medical event and suggests that the incorporation of physicians into a mass gathering setting may be associated with an absolute increase in patient census and transports, while decreasing the percent of patients transported. The impact on local emergency medical services and ED resources, although not specifically investigated in this study, was likely minimal.     

Medical care at mass gatherings: considerations for physician involvement

Although many authorities define a "mass gathering" as a group exceeding 1,000 persons, several times that number likely are to be present. The event for which the group will gather may be anything from a rock concert to an Olympic competition. Preparations for the event can be minor or major. This article reviews the issues that a physician should consider if he or she chooses to become involved in the delivery of medical care to such populations, as well as the evidence suggesting that a physician should be involved in most such gatherings. Emergency medical care at public gatherings is haphazard at best and dangerous at worst. There are surprisingly few data from which to plan the emergency medical needs for public events and no recognized standards or guidelines for providing emergency medical services at mass public gatherings.     

Anticipating Demand for Emergency Health Services due to Medication-related Adverse Events after Rapid Mass Prophylaxis Campaigns

Objectives: Mass prophylaxis against infectious disease outbreaks carries the risk of medication‐related adverse events (MRAEs). The authors sought to define the relationship between the rapidity of mass prophylaxis dispensing and the subsequent demand for emergency health services due to predictable MRAEs. Methods: The authors created a spreadsheet‐based computer model that calculates scenario‐specific predicted daily MRAE rates from user inputs by applying a probability distribution to the reported timing of MRAEs. A hypothetical two‐ to ten‐day prophylaxis campaign for one million people using recent data from both smallpox vaccination and anthrax chemoprophylaxis campaigns was modeled. Results: The length of a mass prophylaxis campaign plays an important role in determining the subsequent intensity in emergency services utilization due to real or suspected adverse events. A two‐day smallpox vaccination scenario would produce an estimated 32,000 medical encounters and 1,960 hospitalizations, peaking at 5,246 health care encounters six days after the start of the campaign; in contrast, a ten‐day campaign would lead to 41% lower peak surge, with a maximum of 3,106 encounters on the busiest day, ten days after initiation of the campaign. MRAEs with longer lead times, such as those associated with anthrax chemoprophylaxis, exhibit less variability based on campaign length (e.g., 124 out of an estimated 1,400 hospitalizations on day 20 after a two‐day campaign versus 103 on day 24 after a ten‐day campaign). Conclusions: The duration of a mass prophylaxis campaign may have a substantial impact on the timing and peak number of clinically significant MRAEs, with very short campaigns overwhelming existing emergency department (ED) capacity to treat real or suspected medication‐related injuries. While better reporting of both incidence and timing of MRAEs in future prophylaxis campaigns should improve the application of this model to community‐based emergency preparedness planning, these results highlight the need for coordination between public health and emergency medicine planning for infectious disease outbreaks to avoid preventable surges in ED utilization.     

THE ROLE OF THE SPORTS PHYSICAL THERAPIST-MARATHON EVENTS

The role of the Sports physical therapist (PT) as a part of the sports medical team at marathon-type events varies widely. The PT can assume the role of an emergency medical responder (EMR) whose primary role is the management of the athlete in emergency type situations. The role of the EMR extends beyond the care of the athlete to the care and safety of the spectators. In this role, the PT must be prepared to handle any type of emergency situation, which may occur from medical conditions to acute orthopedic/sports injuries, to medical conditions which may be found in the participants of the race or the spectators. Additional roles of the PT can be in pre-race education, pre-participation screening/physicals, and other concerns by the participant related to injury prevention. Regardless of the role assumed by the PT, prior planning is essential for the safety, security, and maximal performance of the participant and to make the race enjoyable and safe for everyone.

Level of Evidence:

5     

How to cope with a visit from the Pope

A mass gathering always presents a challenge to the medical providers of a city since preparations must be made to cover any potential disasters, big or small. With a prediction of several hundred thousand people coming to the New York City area to participate in the Papal Masses, the New York City-Emergency Medical Services readied its forces of physicians, paramedics, and emergency medical technicians from throughout the region. Extensive multi-agency planning involving a Total Quality Management process was integral to the success of covering the events.     

Analysis of patient load data from the 2002 FIFA World Cup Korea/Japan

INTRODUCTION: Past history of mass casualties related to international football games brought the importance of practical planning, preparedness, simulation training, and analysis of potential patient presentations to the forefront of emergency research. METHODS: The Japanese Ministry of Health, Labor, and Welfare established the Health Research Team (HRT-MHLW) for the 2002 FIFA World Cup game (FIFAWC). The HRT-MHLW collected patient data related to the games and analyzed the related factors regarding patient presentations. RESULTS: A total of 1661 patients presented for evaluation and care from all 32 games in Japan. The patient presentation rate per 1000 spectators per game was 1.21 and the transport-to-hospital rate was 0.05. The step-wise regression analysis identified that the patient presentations rate increased where access was difficult. As the number of total spectators increased, the patient presentation rate decreased. (p < 0.0001, r = 0.823, r2 = 0.677). CONCLUSION: In order to develop mass-gathering medical-care plans in accordance with the types and sizes of mass gatherings, it is necessary to collect data and examine risk factors for patient presentations for a variety of events.     

Prehospital severity scoring at major rock concert events

INTRODUCTION: Rock and contemporary music concerts are popular, recurrent events requiring on-site medical staffing. STUDY OBJECTIVE: To describe a novel severity score used to stratify the level of acuity of patients presenting to first-aid stations at these events. METHODS: Retrospective review of charts generated at the first-aid stations of five major rock concerts within a 60,000 spectator capacity, outdoor, professional sports stadium. Participants included all concert patrons presenting to the stadium's first-aid stations as patients. Data were collected on patient demographics, history of drug or ethanol usage while at the concert event, first-aid station time, treatment rendered, diagnosis, and disposition. All patients evaluated were retrospectively assigned a "DRUG-ROCK" Injury Severity Score (DRISS) to stratify their level of acuity. Individual concert events and patient dispositions were compared statistically using chi-square, Fisher's exact, and the ANOVA Mean tests. RESULTS: Approximately 250,000 spectators attended the five concert events. First-aid stations evaluated 308 patients (utilization rate of 1.2 per 1,000 patrons). The most common diagnosis was minor trauma (130; 42%), followed in frequency by ethanol/illicit drug intoxication (98; 32%). The average time in the first-aid station was 23.5 +/- 22.5 minutes (+/- standard deviation; range: 5-150 minutes). Disposition of patients included 100 (32.5%) who were treated and released; 98 (32%) were transported by paramedics to emergency departments (EDs); and 110 (35.5%) signed-out against medical advise (AMA), refusing transport. The mean DRISS was 4.1 (+/- 2.65). Two-thirds (67%) of the study population were ranked as mild by DRISS criteria (score = 1-4), with 27% rated as moderate (score = 5-9), and 6% severe (score > 10). The average of severity scores was highest (6.5) for patients transported to hospitals, and statistically different from the scores of the average of the treated and released and AMA groups (p < 0.005). CONCLUSION: The DRISS was useful in stratifying the acuity level of this patient population. This severity score may serve as a potential triage mechanism for future mass gatherings such as rock concerts.     

Variables influencing medical usage rates, injury patterns, and levels of care for mass gatherings

OBJECTIVES: Mass gatherings create difficult environments for which to plan emergency medical responses. The purpose of this study was to identify those variables that are associated with increased medical usage rates (MURs) and certain injury patterns that can be used to facilitate the planning process. METHODS: Patient information collected at three types of mass gatherings (professional American football and baseball games and rock concerts) over a three-year period was reviewed retrospectively. Specific variables were abstracted: (1) event type; (2) gender; (3) age; (4) weather; and (5) attendance. All 216 events (total attendance 9,708,567) studied were held in the same metropolitan region. All MURs are reported as patients per 10,000 (PPTT). RESULTS: The 5,899 patient encounters yielded a MUR of 6.1 PPTT. Patient encounters totaled 3,659 for baseball games (4.85 PPTT), 1,204 for football games (6.75 PPTT), and 1,036 for rock concerts (30 PPTT). The MUR for Location A concerts (no mosh pits) was 7.49 PPTT, whereas the MUR for the one Location B concert (with mosh pits) was 110 PPTT. The MUR for Location A concerts was higher than for baseball, but not football games (p = 0.005). Gender distribution was equal among patrons seeking medical care. The mean values for patient ages were 29 years at baseball games, 33 years at football games, and 20 years at concerts. The MUR at events held when the apparent temperature was 80 degrees F significantly lower statistically than that at events conducted at temperatures <80 degrees F were (18 degrees C) (4.90 vs. 8.10 PPTT (p = 0.005)). The occurrence of precipitation and increased attendance did not predict an increased MUR. Medical care was sought mostly for minor/basic-level care (84%) and less so for advanced-level care (16%). Medical cases occurred more often at sporting events (69%), and were more common than were cases with traumatic injuries (31%). Concerts with precipitation and rock concerts had a positive association with the incidence of trauma and the incidence of injuries; whereas age and gender were not associated with medical or traumatic diagnoses. CONCLUSIONS: Event type and apparent temperature were the variables that best predicted MUR as well as specific injury patterns and levels of care.