Mass Gatherings



Mass gathering medical care generally refers to the organized care provided for groups of at least 1000 people, including both spectators and participants, although some authors put this number as high as 25,000.13 The event types range considerably from large community events such as parades, fundraisers, festivals, and fairs to political rallies, religious events, sporting competitions, and outdoor and indoor performances such as music concerts. However, to define a mass gathering simply by the number of participants is inadequate.1 A more conceptual definition has been suggested by Arbon, which endorses the idea that a mass gathering is a collection of people that because of its inherent features including density of people, location, or environment may limit medical access.1 Mass gatherings occur in nearly every conceivable location and condition and hence pose unique challenges to the medical provider for planning purposes and provision of medical care.



Despite a long social history of mass gatherings in the United States, the first medical literature reviewing health care in mass gatherings surfaces in the 1960s when volunteer health care providers supported antiwar demonstrators.4 During the ensuing decades, a reservoir of case reports provided information for medical planning and provision at specific mass events such as stadiums, concerts, and the Olympics. In 1990, ACEP released a guide for medical care for crowds,5 and in 2000, NAEMSP released a National Position Paper titled “Mass Gathering Medical Care,” which called for a rigorous scientific evaluation of medical care delivery in place and the adequacy of care, an assessment of injury patterns, and minimum standards for preparation and delivery of medical care.6 The statement also introduced the concept of the medical action plan and the medical director’s checklist.7



Hundreds of millions of people attend mass gathering events every year in the United States alone.8

Consistent in the literature is the fact that even though large-scale mass gatherings are composed of relatively “well” proportion of the population, injuries are generated more frequently at mass gathering events than in the general population.



  • Describe types of mass gatherings and discuss varying needs based on type.

  • Describe common medical conditions and complaints at mass gathering events.

  • Discuss factors that can lead to widespread illness and development of an MCI.

  • Describe the role of the event medical director.

  • Describe types of personnel utilized in event medical support.

  • Describe event medical support planning and essential factors of consideration (eg, number of participants, access, communication, supplies, local medical resources, etc).

  • Describe environmental factors that play a role in event planning and operational adjustments.

  • Discuss contractual arrangements and terms that are important to successful medical support of mass gathering events.

  • Discuss CQI and research initiatives specific to mass gathering events.

  • Provide a basic event medical planning checklist/medical needs assessment form.

  • Provide lists of common equipment for large-scale events.




Medical incidents at mass gatherings and events can be separated into primary care, emergency care, and major incident.9 The medical components should include accessible primary care stations inside the event, response elements embedded within, and transportation staged in a well thought-out location nearby. Gatherings also provide vulnerability to participants by the simple nature of a crowd effect, density, relative anonymity of would-be criminals and have recently served as targets for terrorists10 (Atlanta Olympics, Boston Marathon). This increasing threat of targeted, large-scale violence at mass gatherings requires even more preventative foresight and catastrophe preparation.

Provision of medical care at a mass gathering event can be complex as it integrates multiple aspects of medicine including public health, primary care, and emergency medical services. Management of any medical incident at an event requires coordination with the other logistical elements intrinsic to the event itself including security, event coordinators and staff, and the participants or public.11 In addition, Arbon describes three elements that affect the health of participants including environmental factors, the psychosocial component of the crowd, and the biomedical aspect which includes the overall baseline health of participants and may include widespread involvement of drugs or alcohol.12


The most common types of mass gatherings are sporting events, concerts, and various festivals, fairs, and religious gatherings. Sporting events most often cited in the literature include the Olympic Games and those played at the collegiate or professional level.1321 Many of these are held in fixed stadiums with nonmoving crowds and difficult access to care. Other athletic events such as triathlons, endurance races, and other long distance events are more spread out, requiring medical assets to be staged throughout the course.22

Similar to stadium-based sports, concerts generally have fixed and nonmobile crowds unless multiple stages exist. Rock concerts in particular have been associated with higher patient presentation rates due to drugs, alcohol, and mosh pits.2326 Fairs and festivals, on the other hand, are generally spread out with a large number of participants over multiple days and therefore pose their own unique problems in regard to planning and staffing.2732


Most patient complaints can be categorized as either traumatic, medical, or support. As mentioned previously, certain events (ie, rock concerts) are more likely to produce specific types of patient complaints (ie, orthopedic injuries). Several mass gatherings have been described in the literature, documenting specifically the rates of patient presentations and chief complaints. A retrospective review of the New York State fair over a 5-year period showed an average patient presentation rate (PPR) of 4.8/10,000. The three most common complaints were dehydration (11.4%), abrasions/lacerations (10.6%), and falls (10.2%) (Table 68-1).30

TABLE 68-1

Top 3 Complaints at the New York State Fair (2004-2008)

Other events, such as concerts, would be expected to have more traumatic injuries. A review of 405 major concerts in the 1990s showed that rock concerts had approximately 2.5 times more patients than nonrock concerts.24 However, the distribution between traumatic injuries and medical complaints were the same. Other events that produce traumatic injuries include outdoor races, demonstrations, and rallies, events that include active participation such as climbing or fighting, and events that utilize dangerous elements such as pyrotechnics.8,27

There are many characteristics that can be used to predict the types of injuries to expect. In a 2002 review of the literature, Milsten et al identified the most common variables affecting injury rates and injury types which included venue size and participant numbers, among others (Box 68-1).8 Duration of the event, venue type, and location are also major variables in predicting patient load. Events held indoors vary based on spectator mobility.

Box 68-1 Most Common Variables Affecting Injury Rate/Type


Event type

Event duration


Crowd mood and density


A study reviewing injuries at an Olympic venue showed higher rates for mobile crowds vs seated crowds.8,13 Indoor events should be evaluated for points of egress and other barriers. Venues held outside have many contributing factors. Environmental exposure to excesses of heat and cold are major contributors to health problems at mass events.7,8,12 Preparations for exposure should be taken seriously. Leonard points out the following common-sense fact: whatever is in or around the venue that can produce injury should be expected to produce injury (ie, if there is water, anticipate drownings; if there is elevation, consider falls; if proximity to insects or animals, expect bites, etc).5,8

Certain crowd demographics can also predict injury patterns and rates and should be considered when planning. The age of the population—older crowds are generally more frail and have preexisting health problems. The mood of the crowd- the density of the participants, and the consumption of drugs and/or alcohol have been shown to affect injury patterns and rates, as mentioned previously.5,8,12

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Jan 22, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Mass Gatherings

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