Defining mass gatherings and special events

Mass gatherings present unique challenges to EMS as they put pressure on the surrounding emergency response systems. History demonstrates that they can produce, or are vulnerable to, escalating events such as crowd disturbance, fire, structural collapse, natural disaster, disease outbreak, or terrorist attack. Mass gatherings are not isolated events. Despite best efforts to manage and contain events within normal operations, they often strain peripheral resources, including EMS, hospitals, transportation, and law enforcement. As a result, when a mass casualty incident (MCI) occurs during a mass gathering, emergency services are often already saturated and the response is compromised.

Traditional mass gathering planning has concentrated on normal operations using historic patient presentation rates from comparable events [1]. As a result, when an escalating event does occur, conventional planning tools and available resources are generally not prepared to manage the catastrophe. However, with proper planning and tools, a mass gathering can not only be better prepared for an escalating incident during the operational period, but can also be used as a disaster response training exercise between collaborating response services.

This chapter reviews the definitions and types of mass gatherings, provides a historic perspective of MCIs that have occurred at mass gatherings, covers planning and management methodology, highlights unique EMS capabilities that are useful for response within mass gatherings, and presents MCI tools and lessons learned from case studies of prior experiences.

The goal of this chapter is to go beyond the traditional role of preparing for normal operations at mass gatherings by integrating MCI planning and tools to address historical vulnerabilities and emerging threats. The vulnerabilities that mass gatherings expose can be converted into an opportunity by using these events as repeatable training exercises for MCI response. These exercises incorporate many of the actors required to respond, which forges interagency relationships and facilitates application of the procedures and protocols. Mass gathering planning that includes preassignment of MCI leadership roles, predesignation of disaster communications channels, coordination with regional hospitals, integration of unique EMS tools and capabilities, staging of disaster supplies, recognition and mitigation of historic vulnerabilities, and preservation rather than saturation of regional resources with physician-based treatment centers will better prepare for normal operations as well as for a MCI.

Types of mass gatherings and definitions

There is a broad variety of mass gatherings that vary in scale, location, and nature of event. Large athletic events, rock concerts, religious celebrations, and street fairs will each present a different set of challenges to planners. A mobile and open event, such as a marathon, that is spread across a city will differ significantly from an enclosed, ticketed event at a stadium. The nature of the attendee will also influence the challenges faced. For example, a rock concert may have a higher potential for substance abuse and violence while a religious celebration might have a higher number of elderly or infirm participants [2]. The scale of planning will differ greatly for a local parade, when compared to a large-scale event such as the Olympic Games, which requires planning and coordination at the federal and international level.

Mass gatherings have varied definitions as well as terms to describe them. Some authors define mass gatherings as over 1,000 persons [3], but most published data are for events with greater than 25,000 persons in attendance [4]. The United States Federal Emergency Management Administration (FEMA) uses the term “special events.” The operational definition that FEMA uses for the Special Events Contingency Planning Job Aids Manual is:

…a non-routine activity within a community that brings together a large number of people. Emphasis is not placed on the total number of people attending but rather the impact on the community’s ability to respond to a large-scale emergency or disaster or the exceptional demands that the activity places on response services. A community’s special event requires additional planning, preparedness, and mitigation efforts of local emergency response and public safety agencies [5].

The World Health Organization similarly defines a mass gathering as “…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” [6]. The definitions do not focus on the number of attendees; rather, they recognize that mass gatherings will strain surrounding resources. Therefore, mass gathering planning must recognize that these events are not isolated and must account for the surrounding system pressures that are generated by the event.

History of disasters and mass casualty incidents at mass gatherings

From a theater fire in Canton, China in 1845, that claimed over 1,600 lives, to a riot at a soccer game in 1964 in Lima, Peru, that had approximately 300 fatalities, to a crowd surge in Mecca, Saudi Arabia, in 1990 with over 1,600 deaths, history demonstrates that disasters and MCIs occur at, or are caused by, mass gatherings [2,7]. Every year at mass gatherings held across the globe, attendees fall victim to the consequences of poor planning, inadequate preparation, or violence. Soomaroo and Murray found that there are several common causes of these disasters as well as areas of mitigation in planning that can help prevent loss of life [8]. The five general areas of risk management and planning mitigation that were identified were overcrowding and crowd control, event access points, fire safety measures, medical preparedness, and emergency response.

Overcrowding and inadequate crowd management and control are a recurrent cause of MCIs at mass gatherings. Crowd densities and pedestrian traffic flow patterns create predictable patterns of behavior and bottlenecks. In dense crowds, people are often unable to see what is happening only a few feet ahead and this can exacerbate a crowd crush with pushing behaviors. Stairways, tunnels, turns, equipment, and stages can all create obstacles that will impede traffic flows. In addition, stimuli such as weather changes, event cancellation, crowd violence, rumor of danger, intoxicated individuals, or structural collapse can create a sudden surge in the crowd that may cause individuals to fall and be crushed regardless of strength or size. Some of these risks can be avoided with a properly designed venue that is appropriate for the event.

Ticketed and controlled event access points can help control the number of attendees and provide additional security screening. Access points that are used for both entrance and exit will have greatly reduced traffic flows. An adequate number of clearly marked emergency exits that are not blocked in an emergency can help prevent loss of life in the event of a catastrophe.

Robust fire safety, prevention, and response measures can prevent loss of life. Examples include using approved site construction materials and strict enforcement of fire safety codes, such as set numbers of extinguishers in each temporary structure present.

Medical preparedness and emergency response planning can help manage an event during normal operations and also prepare for an escalating event. Traditional planning has focused on suggesting the number and type of medical personnel based on historic patient presentation rates at similar events under normal circumstances. However, there often is a disconnect and lack of recognition that events commonly saturate emergency services on one hand, yet the expectation remains that these stretched services will be able to effectively respond to an escalating event. Practical budget constraints coupled with the improbability of a major disaster will generally not allow for the number of medical personnel on scene that would be required to manage a MCI. However, planning, staging, and education can help prepare event providers with the necessary tools to better manage the early, critical stages of an MCI. Mass gathering medical operations share many characteristics of MCI management and as a result can be used as an opportunity for repeatable training exercises for all levels of community response [9].

Emergency response must be preplanned. Emergency access corridors must be protected and maintained for responders. Proper communications are necessary for both crowd management and emergency response.

Role of the medical director

The medical director should be knowledgeable in EMS, emergency medical conditions and treatment, and the logistical and personnel limitations inherent in mass gatherings. The goals of medical service are to establish rapid access to the injured or ill patients; provide triage, stabilization, and transport for seriously injured or acutely ill patients; and provide on-site care for minor injuries and illnesses, thereby preserving the EMS function in the surrounding community [10].

The medical director responsible for the planning and provision of medical care at a mass gathering must understand the interrelated consequences of all the planning variables. While the medical director is primarily responsible for the provision of medical care, he or she must be an active participant in many aspects of the planning phase to identify risks and operational concerns. Major system failures are often caused by an interrelated cascade of decisions and smaller failures that converge to create chaos. Although not all vulnerabilities can be foreseen, each area must be reviewed for weakness and potential failure.