Mass gathering medical care refers to the provision of medical services to organized events or venues with relatively large numbers of people in a defined geographic area. Typically, mass gatherings are considered to be events that have at least 1000 people; however, this does not have to be the case.^1,2 Although the principles of mass gathering medical care traditionally apply to congregations of large numbers of people, these principles also apply to smaller venues with a relatively high concentration of people in a limited space and those where it may not be easy to access the general system of EMS. Therefore, the principles of mass gathering medical care also apply to athletic events with fewer than 1000 people, as well as airplanes, cruise ships, and wilderness environments.

Table 4-1 lists some of the major factors affecting planning for a mass gathering event. Physical barriers may inhibit easy entry and exit from the site. These barriers can make it difficult to get medical resources into, and to get patients out of, the event location. Reliable communication between medical personnel, event organizers, and outside medical resources is key to a successful medical response. Environmental factors will also affect the response, especially at extremes of cold, wet weather that can precipitate hypothermia or hot weather that can precipitate dehydration and heat stroke. Finally, event planners should consider possible public health threats of widespread communicable disease and the potential for a terrorist attack with explosive or other devices.

The need for mass gathering medical care was first described after two spectators collapsed and died during a University of Nebraska football game in 1965.³ The event organizers were not prepared to manage medical emergencies in the midst of the event, and consequently, when these two patients needed medical care, the organizers were not able to meet the need. Medical directors have become experienced in mass gathering medicine, and case reports are described for sporting events, concerts, expositions, and other large congregations of people.²

One of the largest global gatherings, the Islamic Hajj pilgrimage to Mecca, Saudi Arabia (reaching 2.5 million in 2009), has required officials to manage threats to public safety from outbreaks of infectious disease to major traumatic injuries from stampedes. Other notable global mass gatherings include the 2010 World Expo in Shanghai, China, which attracted approximately 70 million visitors, and the FIFA 2010 World Cup in South Africa, during which more than 1 million foreign visitors entered the country.⁴ As large-scale global mass gatherings become more common, it is evident that there is a need for a global effort to develop the science of mass gathering medicine. This is exemplified by the mass gathering conference held in collaboration with the Kingdom of Saudi Arabia Ministry of Health in Jeddah, Saudi Arabia, in 2010⁴ and the formation of an online registry for mass gathering data collection as developed by the University of British Columbia.⁵

Interestingly, despite the fact that mass gatherings are generally attended by individuals in good health, these events tend to have a higher incidence of illness and injury than that which would be found in the general population.⁶ The incidence of usage of medical care at mass gatherings has been reported to range from 4 to 440 patients per 10,000.² The wide variance in medical usage rate is a function of the type of event and environmental factors.

In preparing for a mass gathering event, medical directors should develop an organized approach through the development of a medical action plan.⁷

PHYSICIAN MEDICAL OVERSIGHT

All mass gathering events should have an identified physician medical director who is responsible for developing the medical action plan. The medical director is also responsible for providing medical oversight before and during the event. This person should be board certified in emergency medicine and have a current medical license from the state(s) where the event will be located. The medical director should also have experience in the medical direction of EMS and the provision of medical care at mass gathering events. In the future, it will be desirable for the event medical director to be board certified in EMS. Experience and training in EMS provide an event medical director with skills in field medicine, including creative thinking, the ability to make diagnostic and treatment decisions purely on clinical grounds, and an awareness of operational environments that are very different from a typical ED.

The medical director is responsible for developing plans for indirect medical oversight and ensuring a coordinated system of direct medical oversight. Indirect oversight describes a system of written protocols that provide the medical personnel with a standardized set of directions for the care of a variety of traumatic and medical conditions that may be encountered during the event. These protocols should always be consistent with local EMS protocols unless the medical director has prior approval from the local jurisdictional EMS medical director to deviate from them. Direct medical oversight describes a method of direct communication with medical providers during the event to answer questions and provide medical direction in real time during the event. Although direct oversight can be delegated to a team of physicians for an event of long duration, ideally, the medical director should plan to be on site during the event as much as possible.

COMMAND AND CONTROL

In addition to an event medical director, mass gathering plans should have an organized system of command and control. Although many systems exist for the command and control of resources at emergency incidents or mass gatherings, one of the most well-tested and efficient methods is the Incident Command System. It was initially developed as a consequence of poor management of a series of wild-land fires in Southern California in 1970.⁸ The system can be used for any type or size of emergency, disaster, or mass gathering, with the purpose of allowing either a single agency or multiple agencies to communicate using common terminology and operating procedures. Further, the ease in putting the system into action allows it to be functional from the time an incident occurs until the requirement for operations no longer exists. In fact, since its original development, the Incident Command System has been adopted by the National Fire Academy and currently provides the structure for the Federal National Incident Management System.⁸

The purpose of establishing a command and control system like the Incident Command System is to define clear lines of reporting and communication among all major functioning components that may coexist during an incident. The organizational structure develops in a modular fashion from the top down and may incorporate five functional divisions.⁸ While the Command function is always established, the other divisions, which include Operations, Logistics, Planning, and Finance, form as needed (Figure 4-1). The incident commander for a mass gathering event ideally should be someone with experience functioning within an Incident Command System structure. A lead fire official would be well suited as the incident commander, because officers in the fire service typically have extensive experience working within the Incident Command System. However, if the local fire department is not involved with the event, as may be the case in smaller events, command should be managed by someone with EMS experience and ideally should not be a physician. As will be discussed later, the physician’s role within the Incident Command System structure should be focused on direct oversight of patient care and not involve the global issues that are the concern of the incident commander. In short, the incident commander must be involved in directing available resources, communicating effectively within the organization, continuously assessing the incident priorities, coordinating activities of outside agencies, and always retaining ultimate responsibility for the incident.

Within a typical Incident Command System, the provision of medical care to the public occurs within the Operations Section. Often referred to as the “doers,” it is the function of the Operations Section to complete the primary tasks of the mission. The medical branch in Operations should establish a similar modular command framework for organizing the various medical teams, each having at a minimum their own team lead. Members of the medical teams include, but are not limited to, EMTs, paramedics, nurses, physician assistants, and physicians. It is not required that the physician take the lead role of each medical team. In fact, it may be more beneficial to have the individual with EMS or fire service experience in the role of team lead, which ideally may be an EMS physician. Depending on the number of agencies involved, there may be more than one EMS medical director on scene. An agency’s medical director should be available for direct medical oversight as needed and should ideally be on site as much as possible. The medical director(s) should function as a commander within the Operations Section and report back to the section head of Operations who ultimately reports to the incident commander. Key to the success of the Incident Command System is that every individual abides by the established hierarchical ranks of command.

Perhaps the most important functional component for ensuring a successful mass gathering event within the Incident Command System structure is the Logistics Section. Logistics personnel are responsible for ensuring that all equipment and supplies are available and in working order when needed. Whereas the Operations personnel are the “doers,” the Logistics personnel are the “getters.” They “get” the supplies needed by Operations. Because the ability to effectively care for the public at a mass gathering event is highly dependent on having a certain amount of supplies, it cannot be stressed enough that a well-functioning Logistics unit is critical to the success of the event. The event medical director should not have to be responsible for acquiring necessary supplies if Logistics is functioning well.

The Incident Command System also provides a framework for accountability of personnel, which is paramount to maintaining safety during a potentially long and unpredictable event. Within each branch under Operations, there should be a designated safety officer. The sole responsibility of this individual is not to provide care, but instead to maintain a system by which all personnel are accounted for at all times. This may include simply keeping a visual account of personnel, which would only be feasible at a very small event, or implementing a method that uses an identification tag that is kept by the safety officer during the time each individual is operational on scene. Each functional unit safety officer should ultimately report to the command staff safety officer for the event, who reports to the incident commander.

Closely related to the concept of accountability is the notion of force protection. This is a term used by the U.S. military to describe preventive measures taken to mitigate hostile actions against individuals. The number one priority in all events is scene safety. It is well known that if a medical provider becomes sick or injured, the provider will use resources intended for the public and distract other providers from the ability to perform their duties. As such, a sick or injured medical provider has the potential to dramatically disrupt the overall medical mission for the event. While medical personnel are always responsible for assessing and assuring their own safety and those with whom they work, it is imperative to have a well-designed plan for the overall medical care and protection of the medical providers at the event. One of the duties of the event medical director is to be prepared to provide care to the other medical providers should the need arise. In addition, communication with law enforcement personnel will help to ensure the overall protection of the medical providers. Their support should be readily available and have the means to immediately respond to any location should the situation become unsafe. Depending on the type of event, threats could range from those that are readily seen (i.e., crowds at a concert) to those that are hidden (i.e., explosives and other weapons carried by an individual with the goal of using mass gathering events to kill and injure).

RECONNAISSANCE

In the beginning stages of preparation, the medical director and assistants need to assess the site to identify the geographic variants that will affect their ability to provide medical care to the public. Within the Incident Command System structure, this establishes a role for the event medical director in the Planning Section. Most important, the planners will need to determine routes of ingress and egress for the event. Backup plans should also be developed. Planners should determine ideal locations for setting up a base of operations, fixed medical care sites, and staging areas for mobile units. Decisions should take into account the effects of predicted traffic flow, predicted sites of high-volume medical need, natural geographic barriers, and location of receiving medical facilities.

NEGOTIATIONS

The process of developing a medical plan for a mass gathering event requires a cohesive teamwork approach with multiple interest groups. First and foremost, the medical planners should develop a plan that meets the needs of the public and the event planners. This first step may require some negotiations with event planners in determining locations for fixed and mobile medical units, level of care to be provided, and resources provided to the medical units. Negotiations will determine if the medical units will be paid under contractual terms by the event planners or if they will volunteer their services to the event. This negotiation stage should also resolve who will finance the purchase of needed supplies and pay for other needed resources, such as costs of transportation and liability coverage.

Regardless of who pays for supplies, it is important that the medical teams coordinate with the Logistics Section to ensure that equipment and supplies are readily available when needed. Similarly, regardless of who is responsible for acquiring supplies, there is value to the event medical director having ultimate control over the acquisition and maintenance of critical medical supplies, as this will ensure that the medical needs of the public are assured.

Medical planners should also establish communication and agreements with other outside agencies that have a potential need to interact with the medical response team for the event. Medical teams that are formed outside the local jurisdictional EMS system should have an agreement with local EMS that addresses transportation of patients out of the event to local resource hospitals. Transfer and acceptance agreements should be developed with the hospitals. Local law enforcement should be contacted for assistance with traffic flow and security. Events that have the potential to be affected by security issues on a national scale may also require agreements with the U.S. Department of Homeland Security for disaster and security response.

HUMAN RESOURCES, LEVEL OF CARE, AND TRAINING

The event medical director should determine the desired level of care for the event based on the predicted medical need and available resources. Depending on the needs of the event, the desired level of care may range from emergency medical responders to physicians. Once the desired level of care and the predicted patient volume are determined, the medical director will be able to develop a plan for human resource needs. These resources may be acquired through the local EMS system, area hospitals, medical training programs, or other sources such as ski patrols and medical reserve corps.

Medical personnel should be licensed to practice at their level of training in the local jurisdiction. Although the medical personnel should be trained for their established level of care, the medical director may want to have additional training sessions to address specific injuries and medical conditions that are predicted to be encountered by the medical personnel during the event. Regardless, it is important that the providers work within a defined scope of practice as determined by level of training and any operational-specific protocols that may be authorized by local authorities for mass gathering events.

EQUIPMENT

When considering equipment for a mass gathering event, planners and medical directors should take into account the type of event, the weather, and the skill level of the medical staff. Medical units comprised of personnel at the EMT level or lower will need to carry significantly less equipment than units staffed by personnel at the paramedic level or higher. Units with physicians may elect to have on hand supplies to do simple suturing and advanced resuscitation. However, thought should be given to the available time needed to suture a wound in balance to the patient volume and the availability of the fixed standing acute care centers. If available, it may be more advantageous to refer patients needing procedures to acute care hospitals. The appropriate way to manage the need for procedures is dependent on the available resources and the overall mission of the medical care at the event.

Often, a large proportion of time spent planning out supplies is focused on generating a broad list and subsequently obtaining supplies that would be necessary to provide medical care for a critical patient. As discussed earlier, it is important to consider that rapid transport of this patient away from the incident to the controlled environment of an acute care hospital may be more beneficial for the patient and free up the provider to care for other patients who would likely not receive evaluation given the time-consuming nature of the critical patient. In addition, proportionally fewer critical patients are seen at a given event compared with the vast majority who seek aid for minor complaints such as scrapes, blisters, headaches, and sprains. Therefore, more effort should be placed on obtaining supplies in highest demand. As suggested by the number and type of complaints seen, those supplies in highest demand typically include bandages, foam padding for blisters, ice for sprains, fluids for oral rehydration, acetaminophen, and ibuprofen.

In general, the incidence of cardiopulmonary arrest and the need for major resuscitation at mass gathering events is low. However, medical units should, at the very least, have access to an automated external defibrillator. Event-specific protocols should address the use of advanced airway equipment, including the possible use of medications for rapid sequence intubation. Plans for other resuscitation needs should also be addressed prior to the event so that all providers manage these small numbers of cases in a standard format (e.g., fluids for sepsis, postresuscitation care, management of cardiac arrhythmia, status asthmaticus). Although it is rare that there is a need for major resuscitation, there may be value to having supraglottic airways (e.g., KING LT Airway^®) and adult intraosseous needles (e.g., EZ-IO^®).

In addition to the level of training of the medical staff, equipment needs will be determined by the mobility of the unit. Some events may need mobile medical units that are able to reach patients in difficult locations or easily move through large crowds. Units on foot and other nonmotorized means of travel will be able to carry fewer supplies than those using motorized vehicles such as golf carts. For events using nonmotorized mobile units, it will be important to design a means to bring heavier supplies to a patient should the need arise, such as equipment needed to manage a patient with a high suspicion of spinal cord injury. Units in fixed locations will be able to stock a greater quantity of materials, possibly including cots, shelter, and additional medical supplies.

Although the equipment needs are unique for each event, there are some things that are universal. Tables 4-2 and 4-3 show suggested items for both mobile and fixed units as well as suggested equipment based on the skill level of medical personnel.