Kumbh Mela Religious Festival accommodations on floodplain.
Medical planners may underestimate the numbers who will require medical attention at such events.20 Avery describes the planning for a papal visit to Coventry in 1982, and suggests that for any gathering of up to 350,000 people, significant planning will be required.18 In 1979, Pope John Paul II held a papal audience in Phoenix Park, Dublin, Ireland, that was attended by more than 1 million people (about one-third of the population). This was one of the highest percentages of a nation’s population in attendance in a confined area for a single event. While data are incomplete, there was only a single fatality recorded at the event that night, a security guard on patrol.
Millions travel to Mecca for the Hajj annually. Every able-bodied Muslim who can afford to do so is obliged to make the pilgrimage to Mecca at least once. More than 2 million persons participate annually and there are excellent data on the various medical aspects of the pilgrims and the additional impact on hospital admissions during Hajj.21–23 Over the years, there have been significant numbers of deaths associated with crushing injuries as the crowd surges across the bridge. Planners have redesigned the bridge as a mitigation strategy.24
Definitions
There is no international standard definition of a mass gathering. The concept of mass gathering medical management has only been described for four decades, possibly because physicians have not had full-time roles in the area. In the United States, ordinances dating from 1974 in North Carolina recognized that “The mass gatherings of people for an extended period of time at one place within Union County, without proper care being taken for the protection of said persons and the public, can create conditions which are detrimental to the health, safety and welfare of the citizens of this County and the peace and dignity of this County.”25
To provide for the protection of public health, property, public welfare, and safety, the Union County Board of Commissioners in North Carolina adopted ordinances that: 1) define mass gatherings and require that permits are obtained; 2) specify creation of detailed maps showing the location of emergency ingress and egress routes and emergency medical facilities; and 3) mandate services must be organized in advance. The ordinance states: “Mass Gathering means the congregation or assembly in which admission is charged or other contributions are solicited, accepted or received, all in reasonable contemplation of profit, of more than 200 people in an open space, or open air for a continuous period of at least six hours.”25
Alleghany County, also in North Carolina, enacted similar ordinances in 1975 that increased the number of people required to define a mass gathering to 300.26 The Arkansas State Board of Health defined 1,000 persons in one place for more than 12 hours as a mass gathering.27 Most authors, when discussing mass gatherings in a modern setting, refer to congregations of more than 1,000 people, although others define a mass gathering as being greater than 25,000 persons.28,29 The precise number must be placed in the context of where the event takes place and what exactly the available medical resources are pre-event. In determining the intensity of care, the level of practitioner staffing, and the type of equipment required at an event site, one needs to consider the following: duration of the event, spectator type, participant numbers and demographics, geography, terrain, and transfer time to access definitive medical care. In 1999, Jaslow published a review of U.S. state legislation and found that only six states had specific EMS legislation governing mass gathering medical care: Connecticut, Iowa, New York, Oregon, Pennsylvania, and Wisconsin.30
For this chapter a mass gathering will be defined as an event that requires special planning to assure capacity and capability for the provision of appropriate medical care to attendees without adversely affecting medical care in the host community. This is similar to the World Health Organization definition of “any occasion, either organized or spontaneous, that attracts sufficient numbers of people to strain the planning and response resources of the community, city or nation hosting the event.”31
The nature of the event, including its size and duration, the numbers and demographics of participants, and its geographic location are important considerations. In contradistinction to the sample ordinances, this definition deliberately avoids using numbers to classify a mass gathering. Consistent with the philosophy of this book, the key consideration is the functional impact of the event rather than the absolute number of people involved.
To determine effects on baseline medical services, events must be considered within the context of the involved community. Medical resources must be planned to mitigate any potential negative effects on routine medical care during the mass gathering.
Classification of Mass Gatherings
A classification system for mass gatherings can aid in the planning process internationally and also achieve a commonality of language for describing future events. Although using numbers of participants alone has limitations, some authors have suggested this approach to determine the resources required for planning (Table 19.1). The majority of physicians involved in providing mass gathering medical care will participate in events that have less than 100,000 attendances. There are considerable differences between providing care at a local community event where the attendance will be less than 1,500 compared to providing medical support in football stadiums or rock concerts where the attendance will be up to 100,000. However, the commonality between small, medium, and large mass gathering events is the recurrence of such events on sites within the community and institutional memory aiding in preparations for the following week’s, month’s, or year’s events.
| Mass Gathering Classification | |||||
|---|---|---|---|---|---|
| Class | Subclass | Numbers Involved | Resources Required | Example | Planning Process |
| Mass gathering | Small Medium Large | 200–1,500 1,500–10,000 10,000–100,000 | Local Local Local + Country | Local fair Local sports game Concert/sports game | 1–2 months 1–2 months 6–12 months |
| Major Mass Gathering | 100,000–250,000 | Regional +/– National | Large music festivals | >12 months | |
| Super Mass Gathering | 250,000–500,000 | National | Motor sports events | >12 months | |
| Extreme Mass Gathering | 500,000–1,000,000 | National +/– International | Religious festivals | 12–24 months | |
| Mega Mass Gathering | 1,000,000+ | National + International | Papal visits, Haji | 12–24 months | |
Larger events identified as “major mass gatherings” have been defined as those with an attendance between 100,000 and 250,000. These are associated with the added difficulties of mass transit, creation of suitable treatment and potential accommodation facilities, and public health issues for those in attendance. These events typically can last a number of days.
“Super mass gatherings” are those with attendance between 250,000 and 500,000. Commonly these will be sporting events with mass attendance such as NASCAR, Formula 1, the Olympic Games, or football world cups. These will require significant coordination of medical teams where events are longer than 1 day in duration.
“Extreme mass gatherings” and “mega mass gatherings” require significant planning and commonly will be religious events, state funerals, significant political party conventions, inaugurations, or political demonstrations. The majority of these will be planned events for which there will be considerable warning. Recurrent religious festivals such as Hajj and Kumbh Mela will have significant event history and year-round preparations for the next iteration of the event. The true spontaneous events of such size will be political demonstrations such as have occurred in recent years in Egypt. State and political funerals leave little time for preparation but will have significant state and regional involvement in their planning.
Some mass gatherings reduce emergency department visits, probably due to spectators remaining in their homes watching the event on television.32,33 Events that are recurring (local annual fairs, the Hajj, Kumbh Mela) yield historical data useful for planning future iterations. Planners can estimate resource needs for major sports events like American football, athletics, NASCAR, baseball, golf, rugby, or soccer that recur regularly in the same location.34–38 Using the same team for each event recurrence reduces training requirements and can enhance team dynamics in the disaster setting. McCarthy et al. outline how community disaster resilience can be enhanced through effective planning for mass sporting events.39
This cycle of event, analysis, training, planning, and new event should be the goal for those involved in organizing mass gathering medical care. One drawback of frequent events is that they can lead to complacency. A varied training program emphasizing elements of trauma; cardiac, pediatric, and major incident care; and specific hazards will help mass gathering staff remain vigilant to potential threats.
History of Mass Gathering Medicine
Mass gathering medicine is a relatively new concept. The first mention in the modern UK literature was a short piece entitled “The Price of Pop” in Lancet in 1971.40 The author describes the effect of a pop festival on a small island community with a population of about 120,000. Attendance at the festival was estimated to be 250,000 people at maximum. This temporary tripling of the population created traffic, noise, food supply, and sanitation problems. The author suggests: “Open-air pop festivals lasting two or three days may be a passing phase, but other fashions may encourage similar gatherings and conditions.”40 Mass gatherings have grown in frequency and size since this initial description. Kumbh Mela has been described in medical journals such as the British Medical Journal as far back as 1895, when 2 million pilgrims attended the event and specific mitigation strategies were developed to prevent the spread of cholera. However, no other descriptions of medical preparations were identified.
Provision of organized mass gathering medical care in the United States dates back to at least the 1960s. After the death of two spectators at a university football stadium in the state of Nebraska, organizers instituted a system whereby staff and equipment were strategically placed within the stadium to facilitate a rapid emergency response.41 As a result of historic disasters in the UK and Ireland, procedures for treating urgent casualties have been in place for almost a century in many sports venues (Table 19.2). Initially the focus was on protecting participants rather than spectators. In the 1960s, disaster planners created the forerunner to BASICS with the goal of providing medical assistance to ambulance services at scenes of accidents, emergencies, or major incidents such as mass-casualty events. In 1977, healthcare leaders founded BASICS, a system that provides regional teams for disaster response throughout the UK.42 Many of its members provide mass gathering medical care at stadiums.
Deaths in United Kingdom Football Stadiums
| Year | Stadium | Cause | Deaths | Injuries |
|---|---|---|---|---|
| 1888 | Valley Parade, Bradford | Railings collapse | 1 | 3 |
| 1902 | Ibrox Park, Glasgow | Terrace collapse | 26 | 550 |
| 1939 | Rochdale Athletic Ground | Roof collapse | 1 | 17 |
| 1946 | Bolton | Crushing | 33 | 400 |
| 1957 | Shawfield, Glasgow | Barrier collapse | 1 | 50 |
| 1961 | Ibrox Park, Glasgow | Crush on staircase | 2 | 50 |
| 1968 | Dunfermline | Barriers collapse | 1 | 49 |
| 1971 | Ibrox Park, Glasgow | Crushing | 66 | 145 |
| 1985 | St. Andrews, Birmingham | Wall collapse | 1 | 20 |
| 1985 | Valley Parade, Bradford | Fire | 56 | hundreds |
| 1989 | Hillsborough, Sheffield | Crushing | 96 | 400+ |
| 1993 | Cardiff Arms Park | Distress rocket | 1 | 0 |
The Hillsborough Disaster in Sheffield, England, in 1989 is a well-known example of an incident at a mass gathering. At the Football Association Cup semi-final, the opening of a large gate was required to allow those arriving late to enter.43 This resulted in a rapid buildup of supporters on a terrace that was already crowded. There was no escape at the front due to a crowd control ring fence. Large numbers of the crowd suffered asphyxia.44,45 Ninety-six people lost their lives, 81 on-site and 15 more subsequently in the hospital.46 The two local emergency departments received 159 casualties, 155 of these in the first 90 minutes after the incident. All the severely injured were received within 45 minutes and 81 patients were subsequently admitted to the hospital. DeAngeles described a similar incident in the United States that resulted in eighty persons being injured by crushing or trampling during a crowd surge at a college football game.47 On this occasion, eighty-six people were transported to the hospital, ten were admitted for traumatic asphyxia, two had musculoskeletal injuries requiring admission, one patient had a liver injury, and six others were admitted for observation. Several stadium factors were identified that resulted in crush-related injury. Appropriate changes in crowd control policies were implemented.
Another famous historic event is the Bradford City fire disaster in 1985, resulting from a flash fire that consumed one side of the Valley Parade football stadium in Bradford, England.48 The fire engulfed old wooden stands in less than 4 minutes and 53 people died, with more than 250 additional people injured.49 Some of the crowd were so badly burned that they could only be identified from dental records.50 Sharpe wrote about the treatment and triage of multiple burn victims arriving almost simultaneously at the local hospital and the sequence of internal coincidences that ultimately minimized the consequences.51 He subsequently coined the mnemonic COMMUNICATION to help educate other plastic surgeons who may be faced with a similar mass gathering disaster:52
- C
= Chaos
- O
= Order
- M
= Most experienced plastic surgeon
- M
= Make available adequate resources
- U
= Update casualty figures at regular intervals
- N
= No points for economizing
- I
= Inpatient needs
- C
= Capitalize on goodwill
- A
= Accommodation
- T
= Team leader
- I
= Invite outside help
- O
= Outpatients
- N
= Nursing officer
Although this mnemonic was directed at plastic surgeons working in a burn unit, the principles could be adapted to other settings such as the Boston Marathon bombing. Communication failures have been noted as being a major factor limiting effectiveness of response to major disasters. Highlighting the phrase should focus attention on this problem during the response phase.
Internationally, football-related mass gathering disasters (or soccer, as it is known in the United States) have resulted in more morbidity and mortality than most other sports (Table 19.3). Data are derived from multiple sources, and in many cases, it is difficult to determine exact numbers of casualties and deaths. One reason for this is that less seriously injured persons were evaluated by their general practitioners rather than assessed at the site of the event. In some instances, officials blocked media coverage of the disasters and, as was the case with the 1982 football match in Moscow, when dozens of sport spectators were crushed to death, the true magnitude of the disaster did not became evident until many years later, even to those on-site. Morbidity and mortality numbers have been substantial, prompting major changes in the way events are planned and organized. Some of these disasters have occurred in older stadiums where walls, ceilings, or roofs have collapsed. Football authorities have instituted a team licensing system to help prevent this from recurring.
Deaths and Injuries during International Football Disasters
| Year | Stadium | Cause | Deaths | Injuries |
|---|---|---|---|---|
| 1961 | Ibague, Colombia | Stand collapse | 11 | 15 |
| 1961 | Santiago, Chile | Crushing | 5 | 300 approx. |
| 1964 | Lima, Peru | Riot | 318 | 1,000+ |
| 1967 | Kayseri, Turkey | Riot | 48 | 602 |
| 1968 | Buenos Aires, Argentina | Crushing | 73 | 150 approx. |
| 1974 | Cairo, Egypt | Crushing | 49 | 50 |
| 1976 | Port au Prince, Haiti | Firecracker/crush/Shooting | 6 | 0 |
| 1979 | Hamburg, Germany | 1 | 15 | |
| 1979 | Lagos, Nigeria | Riot | 24 | 27 |
| 1980 | Calcutta, India | Riot | 16 | 100 |
| 1981 | Athens, Greece | Crushing | 21 | 54 |
| 1982 | San Luis, Brazil | Shot in riot | 3 | 25 |
| 1982 | Cali, Colombia | Stampede | 24 | 250 approx. |
| 1982 | Algiers, Algeria | Roof collapse | 10 | 600 approx. |
| 1982 | Moscow, Russia | Crushing | 340+ | 0 |
| 1985 | Heysel, Brussels | Riot/wall collapse | 38 | 437 |
| 1985 | Mexico City, Mexico | Crushing | 10 | 100+ |
| 1987 | Tripoli, Libya | Riot/wall collapse | 20 | 0 |
| 1988 | Katmandu, Nepal | Stampede in hailstorm | 93 | 700 approx. |
| 1989 | Lagos, Nigeria | Crushing | 5? | 0 |
| 1990 | Mogadishu, Somalia | Shot in riot | 7 | 18 |
| 1991 | Orkney, Johannesburg, South Africa | Crushing/fighting | 42 | 50 |
| 1991 | Nairobi, Kenya | Stampede | 1 | 24 |
| 1992 | Bastia, France | Stand collapse | 17 | 1,300 approx. |
| 1996 | Lusaka, Zambia | Crushing | 9 | 52 |
| 1996 | Guatemala City, Guatemala | Crushing | 78 | 180 |
| 1997 | Lagos, Nigeria | Locked exits – crushing | 5 | 0 |
| 1997 | Cludad del Este, Paraguay | Roof collapse | 30+ | 200 approx. |
| 1998 | Kinshasa, Dem Republic of Congo | Troops fire on crowd | 4 | 0 |
| 1999 | Alexandria, Egypt | Crushing | 8 | 14 |
| 2000 | Harare, Zimbabwe | Crowd fleeing tear gas | 13 | 0 |
| 2000 | Rio de Janeiro, Brazil | Crushing | 104 | 0 |
| 2001 | Johannesburg, South Africa | Crushing | 43 | 89 |
| 2001 | Seville, Spain | Fence collapse | 28 | 0 |
| 2001 | Lubumbashi, Congo (Zaire) | Crowd fleeing tear gas | 10 | 51 |
| 2001 | Sari, Iran | Roof collapse | 2 | 284 |
| 2001 | Ivory Coast | Riot | 1 | 39 |
| 2001 | Accra, Ghana | Crowd fleeing tear gas | 126 | 93 |
| 2001 | Labe, Guinea | Crushing | 2 | 0 |
In the 1970s and 1980s, football hooliganism was widespread throughout Europe. During the last 15 years, law enforcement communities have successfully cooperated to minimize such activities. Nevertheless, civil unrest before, during, and after games still contributes to significant numbers of deaths.
Types and Sites of Mass Gathering Events
I went to a fight the other night, and a hockey game broke out.
Mass gathering events may take many formats. Researchers have described event-specific aspects of medical care for the following:
Modern arenas or stadiums are equipped with medical facilities built to be compliant with community health and safety standards. In many countries, local governments build municipal stadiums that are licensed to various sporting bodies for use in their particular events. These stadiums are frequently used to host rock concerts and some religious gatherings. Since they are designed as multipurpose stadiums, the basic medical kits and facilities are standardized. For contact sporting events (boxing, mixed martial arts fighting), large rock concerts, or long duration mass gatherings, additional temporary facilities must generally be constructed to meet the increased medical and health needs.
Figure 19.2 shows an example of a well-bounded stadium with wide access and egress routes to prevent crushing at entrance or exits. From this aerial shot, one can see the access roads, free space in the venue, the local town, and the “backstage” area (distant from the stage) in the foreground. This venue accommodates an attendance of approximately 25,000. There are standard first aid areas in all such facilities in Ireland and in many other locations in Europe.
Killarney GAA Stadium: Summerfest 2006. Credit: macmonagle.com.
The Union of European Football Associations (UEFA), the European football regulatory authority, has requirements specifying what facilities must exist to license clubs for competition nationally and throughout Europe, such as in the champions league. These regulations are available at www.UEFA.com or from the national football governing body of the specific country.81 More commonly, a large event takes place in a venue without planned medical facilities, so these must be created de novo.
Figure 19.3 shows an aerial view of Slane Castle, the site of the U2 homecoming concert in 2001. The final qualifying game for the 2002 soccer World Cup was also broadcast live from this venue. Slane Castle is one of Europe’s most scenic natural amphitheaters. De novo facilities were created to manage all aspects of the event, from sanitation to medical care. One of the access roads and one of the gates are visible in the foreground. At this late time of day, the lines are short; however it would not be unusual to have a 1.5-kilometer queue of people outside the stadium waiting for gates to open. The castle itself is in the mid-ground and has been host to many of Ireland’s most memorable rock concerts since 1981. Evident in the photograph is the natural slope from the entrance on the road to the river over 150 meters gradient below. This particular slope can result in significant numbers of traumatic injuries on challenging underfoot conditions in inclement weather. Murphy described the effects on regional hospitals after an event when eighty-eight patients presented to the two local emergency departments with thirteen fractures, six requiring manipulation under anesthesia or formal open reduction and internal fixation.82 The river in the background is another hazard. It is deceptively fast and has claimed lives over the years as concert-goers attempted to swim its course and gain entry for free. In this photograph, more than 84,000 people are located in a very confined space with identifiable access and egress routes. Thus, crowd density would be another potential hazard. This example illustrates the types of challenges that are encountered globally due to geography, topography, and insufficient local medical infrastructure.
Slane Castle 2001: U2 concert.
Current State of the Art
Mass Gathering Event Planning
“Tuas maith, leath na hoibre”
International guidelines for mass gathering event planning are lacking. Countries with well-developed emergency medical systems, such as the United States and the UK, have national guidelines that could be applied in other jurisdictions. In most countries, the demand for medical resources at mass gatherings is sporadic and fulfilled on an ad hoc basis. Requests to physicians and other medical workers are increasing in frequency.61 An ad hoc request made the evening before an event indicating “the need for a doctor for insurance purposes” leaves the physician unprepared. This may be the first time the physician has been asked to provide medical services. No information may be offered on the layout of the venue, the size of the crowd or number of event employees, what medical facilities will be present, or the level of training and equipment carried by the EMS service (which may be a voluntary provider) on that day. Other important elements to know in advance include historical information such as: How many patrons have needed medical attention? Have there been any fatalities? What were the crowd demographics? How many patients were transferred to hospitals?83–85
For large venues, mass gathering event planning may begin up to 2 years prior and should occur no later than 1 year before the expected start date. In some jurisdictions, the event may require licensing by the local authorities or formal planning permissions when the event involves significant change of use for the venue. Examples include a race course transformed to host a large pop festival for 100,000 patrons with on-site camping for 70,000 for 3 days. Considerations include how many medical practitioners would normally work in a town that size and how many would be on call at any specific time. The UK Event Safety Guide has staffing guidelines.86 The tables estimate a minimum number of staff who should be on-site at all times; when considering staffing levels over a 24-hour period, this is paramount. A medical director should be identified at the planning stage and remain involved in the process to ensure that medical matters are addressed and to mitigate any predicted medical risks.
Event planning for a specific mass gathering begins within the organizing body. Once the basic plan is complete, relevant statutory and voluntary agencies are folded into the planning process. Agencies who should be involved early in the planning process include, but are not limited to, those named in Table 19.4. Nations, states, and smaller jurisdictions such as counties may have different requirements for planning and varying processes for appeals when an application for an event license is refused. As a result, timelines for planning must be tailored to local circumstances. In 1996, the ACEP EMS Committee produced guidelines for the provision of emergency medical care for crowds.87 These can be applied in most countries. The National Association of EMS Physicians (NAEMSP) also promulgated guidelines.88 One key NAEMSP planning document is Jaslow’s medical directors checklist.89
Agencies to Involve in Event Planning
| Event promoter |
| Local planning authorities |
| Local public service transport companies |
| Police |
| Fire services |
| Ambulance services (public and private) |
| Voluntary services (e.g., fire and ambulance) |
| Civil defense |
| Local health services |
| Emergency planning/management agency |
| Local hospitals |
| Site owners |
| Event medical officer/command physician and deputy |
| Public relations/media |
Event Planning Timeline
Local Planning Authority
Plans are only good intentions unless they immediately degenerate into hard work.
Calabro and colleagues produced a precise event planning schedule for ACEP in Provision of Emergency Medical Care for Crowds.87 A modified sample event timeline is shown in Table 19.5. A new template is used for each event and planners provide periodic reports to the director. To allow flexibility in accounting for unanticipated delays earlier on the timeline, some index times have few or no specific tasks assigned to them, such as at 14 days, 4 days, and 3 days in this model.
Event Planning Schedule. Modified from Provision of Emergency Medical Care for Crowds: American College of Emergency Physicians87
| Task | 1yr | 6mo | 3mo | 1mo | 14d | 7d | 4d | 3d | 2d | 1d | Event | Post-event | 1d | 3d | 5d | 1wk-1mo |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Define Event | X | X | X | X | X | X | X | X | ||||||||
| Visit site + Walk | X | X | X | X | X | X | ||||||||||
| Event planning meetings | X | X | X | X | X | X | X | X | X | |||||||
| Get site plans | X | X | X | X | X | X | ||||||||||
| Designate + agree responsibilities | X | X | X | X | X | X | ||||||||||
| Designate medical/admin controllers | X | X | X | X | X | |||||||||||
| Develop event medical plan | X | X | X | X | X | X | X | X | X | |||||||
| Develop site emergency plan | X | X | X | X | X | X | X | X | X | |||||||
| Liaise local ED/EMS/trauma units | X | X | X | X | X | X | X | |||||||||
| Ride-alongs to local ED/venue | X | X | X | X | ||||||||||||
| Obtain indemnity/malpractice/insurance | X | X | X | X | ||||||||||||
| Confirm financial arrangements | X | X | X | X | X | X | ||||||||||
| Confirm attendance figures | X | X | X | X | ||||||||||||
| Confirm camping arrangements & review | X | X | X | X | X | X | ||||||||||
| Confirm VIP arrangements & review | X | X | X | X | X | X | X | |||||||||
| Recruit staff + check experience | X | X | X | X | X | X | X | |||||||||
| Generate outline rosters & review | X | X | X | X | X | X | ||||||||||
| Procure + check communications | X | X | X | X | X | X | ||||||||||
| Develop medical protocols/SOPs | X | X | X | X | X | X | X | X | X | |||||||
| Medical staff meeting + agency heads | X | X | X | X | X | X | X | X | ||||||||
| Agree event documentation standard | X | X | X | X | X | X | X | X | ||||||||
| Credential Staff | X | X | X | X | X | X | ||||||||||
| Top up Training | X | X | X | X | X | |||||||||||
| Procure + check clothing | X | X | X | X | X | X | ||||||||||
| Procure + check equipment | X | X | X | X | X | X | X | X | X | X | ||||||
| Check medical facilities siting | X | X | X | X | X | X | X | |||||||||
| Assign staff roles | X | X | X | X | X | X | X | X | ||||||||
| Procure site credentials & review | X | X | X | X | X | X | X | X | ||||||||
| Set Up + build facilities | X | X | X | X | ||||||||||||
| Pre-event briefing | X | X | X | X | ||||||||||||
| Debrief/Hotwash | X | X | ||||||||||||||
| Break up event | X | X | ||||||||||||||
| Post-event audit | X | X | ||||||||||||||
| Plan next event | X |
The event planning schedule illustrates the intensity of resources needed and the complexity of organizing a successful mass gathering event from the medical perspective. For regular events such as weekly or bi-weekly football games, planning may become routine. The event planning timetable for such regular mass gathering events can be further modified by designating index games such as first pre-season, first in-season, and a mid-season game as full detailed planning events and using a shortened 2-week timescale for the others. For regular events, a year-long timescale is impractical prior to the first event in the series. Rather, a permanent stadium back room management team for the professional club can be formed to assist in the planning stages, compress timescales, and serve as part of the overall event medical team. When the event is annual, each task takes more time and the medical director will have a more time consuming role. Effects on the routine work schedules in the weeks leading up to each mass gathering event for both the director and the team members should be considered.
The following sections provide additional detail for each step in event planning as outlined in Table 19.5 (modified from Provision of Emergency Medical Care for Crowds87).
Define Event
Type of event
Duration
Alcoholic beverages: permitting or banning sales, age policy for sales, and volume per sale
Screening for drugs at entrances
Attendance levels
Demographics of attendees (will minors be admitted and are elderly or disabled expected?)
Expected methods of transportation for attendees
Event history, if applicable, with specific details of:
medical usage rates
patient presentations per thousand attendees
number of hospital transports
names and locations of hospitals
outcomes of those transferred
numbers of medical, paramedical, and nursing staff
reports from voluntary aid societies
after action reports
Provide site map/local area map for event planning team
Walk Event Site
Estimate site diameters/circumference
Plan location of access/egress routes for patrons (Use Google Maps for aerial plans)
Identify likely location of main and secondary stages for multistage events
Based on information previously listed, plan location for first aid posts, roaming medical teams, and on-site hospitals
Plan location of access/egress routes for ambulances
Identify potential hazards and mitigate them
Identify likely location of campsites if applicable
Repeat site visit during adverse weather conditions
As can be seen in Figure 19.4, understanding the topography and distances can be vital when planning sites for treatment facilities, on-site transport, and staffing numbers. The site in the figure is from an event with 80,000 attendees, 50,000 of which are in multiple campsites situated around the venue. There are two large open stage areas with capacity of more than 30,000 each and also four marquis facilities with capacities from 2,000–8,000.
Aerial view of Oxegen Music Festival 2007 showing main arena and large tents for other concurrent stage performances with multiple campsites in mid-ground and background for up to 70,000 People.
Event Planning Meetings/Get Site Plans
Regular meetings will take place prior to the event. Some entities like the local emergency planning unit, government health service, and fire and police services will assign a full-time person to this role. For medical personnel, event planning activities will likely represent extra duties. Medical professionals seeking compensation for these additional activities may find it useful to review the planning timeline and calculate a projected time commitment in advance of accepting the position.
Early review of the event site plan allows an analysis of the potential roles for existing medical facilities and ambulance services. Event planners must advocate for using assets that are the most likely to provide necessary medical resources to support the event and not simply use alternate resources that may be more convenient for existing entities.
Designate and Agree on Responsibilities
Occupational health and safety is an important responsibility for the duration of the event. For large gatherings, there may be 5,000 staff on-site and even larger numbers with mega events. In some jurisdictions, medical personnel are required to inform the statutory authorities of industry-related accidents. Thus, a process should be in place to clearly identify medical records specific to staff presentations for work-related injuries. It is important to liaise with the command structures of voluntary aid organizations prior to the event to determine their roles, duties, responsibilities, and reporting relationships.
Specific policies and procedures requiring clarification include: 1) under what authority do accompanying physicians work; 2) who is responsible for the medical actions of non-physicians; and 3) if a major medical incident occurs during the event, how will volunteer workers receive direction from the event medical director.
Designate Medical and Administrative Controllers
The event medical director and deputy should be identified and trained at least 1 year prior to the start of the event for major mass gatherings. A person without hospital-based responsibilities during a major disaster should be selected to avoid competing priorities at event and hospital sites.
On-site management follows similar principles to the incident command system. For large events, the administration section is a key component. Appropriate types and numbers of records must be provided and distributed to the various venue posts. An administrator ensures that required paperwork or electronic data input are completed at all levels and that essential data are seamlessly communicated between various medical facilities. Patient tracking is important and a system should be in place that enables workers to provide information to friends and relatives regarding inquiries on victims’ locations. Privacy of medical records must be maintained at all times.
Develop Event Medical Plan
Few people have real-life experience with mass gathering event planning. For personnel new to the process, communicating with others who have managed similar events and observation of the planning process are useful approaches. Specific planning needs vary by jurisdiction; however, there are several basic areas that should be addressed.
Event and audience demographics
Event medical history
Proximity to definitive care
Contact information for medical staff/event managers/safety officers
Contact information for local hospitals/ambulance services
Event medical command structure
Proposed location of field hospital(s) and level of care offered
Proposed location of satellite units and level of care offered
Proposed location of ambulances and level of care offered
Proposed location of staff and parking facilities
Duties and responsibilities of medical staff
Duties and responsibilities of medical director/site medical officer
Communications chain/structure/contact information/procedures
Documentation and flow of documentation
Procedure for hospital referrals
Develop Site Emergency Plan
The site emergency plan differs from the routine medical plan in that it describes the procedures to follow in the event of a disaster. A standard phrase should be determined that will communicate to all staff that an incident has occurred. Event staff should be capable of performing the following tasks in case a disaster is declared:
Identify staging points
Establish triage protocols
Delineate roles and responsibilities for
Medical incident officer
Triage officer
Casualty clearing station officer
Nursing incident officer
Ambulance incident officer
Identify designated hospitals and liaisons
Establish casualty clearing stations
Find and liaise with other commanders/incident officers (unified command)
Gather data for METHANE message (Table 19.6)
Log events carefully
Identify resource requirements
Liaise with Local Emergency Departments/Emergency Medical Services/Trauma Units
Many EMS systems have designated specialty receiving hospitals for patients meeting certain criteria. Examples include trauma, burn, cardiac, and stroke centers. Protocols in other systems mandate that patients be transported to the closest ED or to the hospital of patient choice. Advanced coordination with ambulance services and local emergency departments will help ensure integration with non-event-related emergency resource needs and appropriate distribution of patients if a disaster occurs.
Ride-Alongs to Local Emergency Departments/Venues
The event medical director should be familiar with local EMS transport times to effectively make an assessment of needed transport resources. Site visits to meet local ED leaders are also important to identify key personnel and understand respective responsibilities and resources prior to an event. Local hospitals may provide information critical to event planning.
Confirm Indemnity/Malpractice/Insurance
Liability is a key concern for physicians and other providers working at a mass gathering. Although some countries have no-fault compensation systems, most general insurers are reluctant to provide medical liability coverage for mass gathering events. In some countries, physicians have malpractice insurance; in others, they possess medical indemnity (discussed in more detail later). For maximal legal protection, medical workers should inform their primary employers and insurers ahead of the event about their expected activities and qualifications to work in such environments.
Confirm Financial Arrangements/Attendance/Camping/VIP Arrangements
Providing financial compensation for event workers will make recruitment easier. Budget calculations and work agreements must be prepared ahead of time.
Projected attendance estimates, including those camping on-site, are necessary to determine medical workforce requirements, particularly for the night shifts. Staffing projections should account for changes in attendees specific for day of the week and time of day (such as campsite overnight).
If significant numbers of VIPs (dignitaries, etc.) are expected, the medical director needs to know in advance. Some categories of VIPs have special security requirements, such as presidents or their families, high-profile politicians, royal families, or other non-performing musical celebrities. Plans must be in place to manage illnesses and injuries if they occur among this group. This is particularly relevant for presidents, as access to services in specific hospitals may be blocked for other patients if a president is being treated.
Recruit Staff and Check Experience/Train and Credential Staff
Staff recruitment, training, and credentialing is extremely time consuming. It is important to ensure that event personnel do not have higher priority competing obligations such as a duty to report to the hospital after a major incident. Community-wide planning is essential to confirm that hospital resources and other components of the healthcare system are not depleted so provision of staff to the event site is possible. If identified staff are not sufficiently trained and certified, the event medical director may need to arrange specific training for the team well in advance of the event. Depending on the jurisdiction, hospital-based physicians may be required to obtain specific medical licensure for prehospital events or may require licensure in another jurisdiction when events occur in multiple countries. The director should consult with local medical licensing authorities to ensure that requirements are met in a timely manner.
Develop Medical Protocols and Standard Operating Procedures
The director, deputy director, and medical team should develop, publish, and distribute medical protocols for medical staff in advance of the event. Standard operating procedures (SOPs) should also be promulgated for first aid and voluntary aid, delineating levels of care and when additional medical help should be requested.
Procure Clothing
Safety clothing is essential for mass gathering events. Team members should be provided with personal gear including safety boots, gloves, and high-visibility clothing. The event organizers should provide event-specific items such as high-visibility vests, caps, and light rain jackets. Logistical considerations, such as ensuring garments fit correctly for all team members, must be made in advance to guarantee timely delivery of specific seasonally appropriate clothing.
Procure Equipment
The medical director should consult with staff on-site for the event and organizers of prior similar events to determine what type and quantity of equipment will be needed. Once requirements are determined, the medical director should make a request to the event organizer to provide funds for purchase or lease of such equipment for the duration of the event.
Generate Rosters/Assign Roles/Procure Passes and Credentials
After calculating the expected number of attendees and the expected population variations over time, staff scheduling by area should begin. The UK Event Safety Guide is a valuable resource for estimating staff requirements.86 Numbers of physicians needed on-site will depend on the training level of volunteers and EMS personnel. Event insurers may also impose requirements distinct from individual physicians’ medical liability providers.
Photographic identification is required at most mass gathering events. It should be collected 7 days in advance of the event to ensure distribution to individual team members (unless the team is travelling together to the venue). Identification should allow access to all areas. If team members are travelling separately, they will need parking passes and route-access passes for any roads that are closed to the public.
Establish Event/Begin Construction/Check Adequacy of Medical Facilities
The first phase of preparing for events classified as large mass gatherings begins 7 days prior with staging equipment in containers for transportation to the venue. The day prior to the event, equipment should be moved to the site and secured overnight. Controlled substances must be kept in double locked containers, preferably off-site until medical staff are present to receive them. A system should be in place to account for restricted drugs and ensure continuous supervision with a responsible worker at shift change. Most events start early in the morning. The medical team should arrive on-site 2 hours before the event and remain at the venue until at least 1 hour after the event closes. The team should take a walk-through tour of the site to familiarize themselves with the locations of their duty stations and their access route to the next higher level of care.
Pre-Event Briefing
On the day of the event, the medical director should organize a briefing for the on-site team that includes information regarding:
Use of radios and channel numbers for communications
Channels of communications to other services
Individual cell phone numbers
Roles and responsibilities
Chains of command
Top medical priorities
Identifying transferring physicians if required to accompany patients
Interaction with other service providers
Importance of documentation
Site orientation
On-site transport possibilities
Location of main medical facility and satellites
Staff rest periods with meals
The briefing should also give instructions on procedures in the event of a disaster/major incident that includes:
Code words to identify a major incident has occurred
Assembly point for re-tasking
Triage protocols
Communication channels
Roles of individual physicians and assigned posts
Debriefing
Mass gathering medical care regulations vary by country and individual locality. In Ireland and the UK, legislation requires medical teams to remain on-site at their posts for a minimum of 1 hour after the event has concluded. For music events, the conclusion of festivities is defined as when the band leaves the stage; for sports events, this definition is met when the teams leave the field. The intent of this requirement is to ensure that an appropriate level of medical care is available for patrons who may suffer a medical event in the process of exiting the mass gathering. In large events, 1 hour may be insufficient for complete egress of patrons, particularly if they must drive from a remote parking facility under crowded conditions. In other confined stadiums, 1 hour may be ample time as patrons walk away from the stadium and board public transport. During this period, it is important for personnel to do a perimeter sweep to ensure that ill or injured patrons are not missed when the event closes.
As the event is closing, there is generally ample time for a roving medical director and deputy to perform a quick debriefing of the medical teams at their posts. Key areas of assessment should include:
What went particularly well?
Were there any areas of concern?
Were the facilities appropriate?
Was the provided equipment appropriate?
What are the areas for improvement?
Were there any patient safety issues?
Were there any staff safety issues?
By visiting staff posts, the medical director can determine whether there are any structural issues that need correction before the next day’s events or for future events. Photographic reminders are useful to document recommendations. Following the debriefing, the director or designee should prepare a written summary of the event that includes patient demographics for the day.
For prolonged events with on-site camping, some staff will be on night shifts. An overlap period with the day shift is helpful to assist night staff with understanding event operations. The director or deputy should be available for debriefing when overnight staff are going off duty. This allows overnight staff to highlight any issues that need attention during the day and to report on the patients treated overnight. Patterns of injury or illness that may be related to recreational drug use, sanitation facilities, or foodborne pathogens should be sought and the public health services alerted in a timely fashion. WHO recently released a very comprehensive “key considerations” document in relation to communicable diseases and response for mass gatherings. It details risk assessment and management, surveillance and alert systems, outbreak alert and response systems, and cross-discipline considerations such as training, logistics, and communication systems.90
Dismantle Event
Event dismantling procedures should mirror the assembly phase. Containers should be repacked, inventoried, locked, and prepared for transport. A detailed inventory of stock used will assist with planning for similar events in future and will also highlight what additions may be needed for the following day at multiple-day events. Any supplies or equipment left on-site at the conclusion of the event (or end of the day for prolonged events) must be appropriately secured. Procedures should be in place to maintain accountability for controlled medications.
The medical director should collate and secure all medical records. Some jurisdictions require a copy of the medical records be submitted to the regional health service authority. Local ordinances or the permit issued for the mass gathering will clarify requirements. For events with camping at locations remote from the main medical facility, establishment of additional medical posts may be needed overnight. Depending on the flow of patrons, these posts may not be in operation during the day when few attendees are expected to remain at campsites.
Medical Reconnaissance
It is a bad plan that admits of no modification.
A site visit by the medical director and deputy can reveal a number of details that may not be evident from reviewing planning applications, architect drawings, or aerial photographs. Venue location, access routes, and topography should all be assessed. Google Maps is a useful tool for generating aerial diagrams of venue sites for the majority of countries worldwide. Maps can show access routes overlain with rail networks. Driving to the event site during peak traffic conditions is useful to estimate transport times to the venue. Per licensing requirements, the start time for the event may be delayed until the medical team arrives. Extra time should be allowed because police and other authorities may alter access routes and change normal traffic flow on event days. For example, roads which may have been bi-directional may only be one-way. The medical director and deputy should remain informed about planned traffic routes to ensure that their team has priority access to routes if such exists. Special parking passes may be required for vehicles and should be secured in advance.
Pre-event visits will also allow the director and deputy to plan ambulance transports from the venue. For large venues, there may be a significant period of on-site travel from the various first aid posts to an ambulance, then another period of travel on-site before the ambulance gets to the access road. At a venue with remote parking or a town nearby, there may be large numbers of attendees walking along the roads to the venue, which may further increase ambulance transport times. These factors affect overall transport times to hospitals. The UK Event Safety Guide has a useful model for predicting resource requirements, including a scoring system for proximity to definitive care.86
Planning should account for the fact that transport times may increase dramatically from baseline during mass gathering events. In addition, some mass gatherings take place in remote venues where the nearest ED may be small and have few resources. Even for a moderately sized facility with an annual ED volume of about 36,000 (less than 100 patients per day), a requirement to transport 100 patients over a 24-hour period would likely exceed surge capacity in that institution. Ryan and Nix in their papers from Ireland in 1994 and 2006, respectively, describe the effect on attendance at local and regional emergency departments for a 3-day festival and a large single-day rock concert.57,91 In Nix’s case, there were 1,355 visits for medical attention on-site over a 2-day festival (3 nights camping at the venue). This represented 1.7% of those in attendance at the event. Milsten in 2003 discussed variables influencing medical usage rates (MURs) and described the term MUR as being the number of presentations for medical care per ten thousand attendees (PPTT).92 For the Nix event, this would result in an MUR of 171, a significant number when compared to Milsten’s own average figures of 4.85 for baseball games, 6.75 for football games, and 30 for rock concerts. Ryan’s MUR of 10 is still significant but was for a much shorter event than Nix’s and resulted in only eighteen patients being transported. Nix reported seventy-two transports during a 3-day event. This represented a 45% increase in workload for the local ED. What is not clear from either report is the number of secondary transfers that occurred from the local ED to regional trauma centers or other specialty facilities due to the need for intensive care services.
The number of physicians deployed at the event may be significantly greater than the number staffing the local ED. What may seem like a small number of referrals from the venue, taking the crowd size into account, may actually overwhelm the local ED, forcing them to go on diversion. This would significantly increase transport and turnaround times with the consequent loss of on-site physicians for longer periods when they accompany patients during transport to more distant hospitals. The local ED may also be unable to accept intubated or other types of critical patients. To guide transport decisions, the site medical director needs to know the current capacity and capability of the local healthcare resources throughout the duration of the event. Historical information as described by Arbon is useful for repeat events.29 This complex model predicts the requirements for patient transports. Requirements for a physician to accompany transported patients must be clearly understood in advance so that staffing levels can be adjusted accordingly. Air evacuation procedures should also be delineated if applicable.
The medical director should communicate with the venue owner or facility manager regarding the site itself, its current usage, drainage patterns, whether tractors have rolled down the grass fields, internal access routes, and use of chemicals on the land. Rolled fields will help prevent ankle injuries. Facilities which have been sprayed with chemicals may result in allergic-type ophthalmological presentations, especially in summer. Hay fever exacerbations may increase in number when large open fields have been cut in advance of the event. Some facility managers may cover the playing surface in a stadium with a temporary surface in order to protect it from damage. This procedure can create inversion effects with microclimates of increased temperature over specific areas and result in increased demands on medical services. In a review article, Milsten described this phenomenon at a rock concert in Denver, Colorado, where a black tarp caused a local rise in temperature of 17°C.93
Additional considerations include the drainage capacity of the land and the locations of internal walkways. If there are areas where water is likely to pool, these should be highlighted on event maps and at campsites; access routes and medical facilities should not be located there. Thousands of patrons could potentially be stranded when attempted to leave the event if parking is situated in an area prone to flooding. If this parking location is unavoidable, contingency plans should be in place for this possibility.
Both director and deputy should walk the site to assess timing of foot travel between the clinical areas, around the circumference of the site, and between the campsite (if present) and the main arenas. In a football stadium, this may be a simple task. In a large open site racecourse, however, where multiple venues and a campsite accommodating over 50,000 people may exist, medical personnel may need on-site transport equipment. Such transportation should be season- and weather-appropriate. As an example, golf carts are unlikely to be useful in muddy or marshy conditions.
VIP care, including access and evacuation plans, should be discussed during the planning stages. In the recent past, Ireland had the highest proportion of helicopters per capita in the world and these were used frequently for VIPs to attend mass gatherings. The event medical plan should address potential hazards from helicopters if they are used. If the VIP area is distant from the on-site medical facility, it may be necessary to establish a separate VIP medical area. Often event promoters will specify this as part of the arrangements from the outset. If this is implemented, support for these facilities should be in addition to the planned numbers required to staff the event.
Local authorities and law enforcement are good sources of information regarding the potential for violence or issues related to drug misuse. They may require the presence of a physician during the search of attendees’ possessions at entry to the venue. This is necessary to verify that tablets and drugs are for legitimate medical use, particularly if they are not in their original dispensed containers. Posters that display the common drugs of abuse can be a useful reference aid at this location.
A reconnaissance visit to the local hospitals and potential referral sites in advance may help to ease the transfer process during the event. The local ED may be small and the addition of 80,000 event attendees may result in significant increases in patient visits.57,82 In some areas, another local hospital may be the best option for referrals. In others, standards may exist for bypassing local facilities and transporting certain types of patients to specialty receiving hospitals like trauma centers. On-site physicians must be familiar with these policies.
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