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EMS in the Fast Lane

Billows2-1

Hundreds of thousands of spectators gather every Memorial Day weekend to sit or stand in the sun for hours, many of them pressed into the crowded infield of the Indianapolis Motor Speedway. Cars fly by them at speeds in excess of 200 mph, sometimes resulting in ultra-high-speed crashes. The Indianapolis 500, the crown jewel of the IZOD IndyCar Series, is known as “The Greatest Spectacle in Racing,” with the largest single-day attendance of any sporting event in the world, held at the world’s largest stadium, the Indianapolis Motor Speedway (IMS). Yankee Stadium, the Rose Bowl, the  Roman Colosseum, Vatican City, Wimbledon Campus and the Kentucky Derby can all fit inside the racetrack.(1)

This obviously presents a unique challenge for those responsible for providing emergency medical treatment to the drivers and spectators under arguably the most demanding conditions. As a result, the medical division of the Indianapolis Motor Speedway has gained considerable experience in managing medical services for hundreds of thousands of people.

Mass-gathering medicine is a complex undertaking. Although much has been written on the subject, there remains no universally accepted definition of a mass-gathering event: Some define it as an event attended by at least 1,000 people, while others say it must be 25,000 or more.

In reality, the number of attendees is only one of the criteria used to define a mass-gathering event. Paul Arbon, in a review published in Prehospital and Disaster Medicine, defines a mass-gathering event as “a situation (event) during which crowds gather and where there is the potential for a delayed response to emergencies because of limited access to patients or other features of the environment and location. This potential delay requires planning and preparation to limit (or mitigate) the hazards … and ensure timely access to appropriate health care is available.”(2)

Preparation
One standard element of mass-gathering events is that they require a significant amount of preplanning and preparation. Reasonable goals for mass-gathering medical care include:

  • The provision of on-site medical care for minor ailments or injuries;
  • The ability to alert medical personnel to the need for assistance;
  • The ability to rapidly access individuals in need of treatment;
  • The provision of appropriate triage in the event of multiple victims;
  • The stabilization of patient conditions as necessary;
  • The avoidance of needless delay in transport of those requiring more extensive treatment;
  • The preservation of the functionality of local EMS systems, to avoid overwhelming the community surrounding the event site; and
  • Partnering with competent equipment and supplies manufacturers to provide standardized equipment and the latest technology to ensure excellent patient care and emergency responder efficiency.


Medical staff should prepare a comprehensive medical plan in advance of each major event that addresses medical direction, level of care, medical reconnaissance, transportation resources, communications, security, public health elements, and command and control. Planning must include all agencies involved in providing resources for the event, including law enforcement, public health services, local fire and EMS services, public utilities and other local health care resources.

Staffing & Resources
Staffing considerations are complex and may change depending on the site size or location, number of spectators, physical layout of the venue and obstacles to response. Past experiences should be used to estimate the potential number of encounters and the necessary number of staff members.

A reasonable goal for access to care is to duplicate the standards of the surrounding community. The Department of Emergency Medicine at the Mayo Clinic College of Medicine recommends an aid station every one-eighth of a mile or five-minute walking distance, a BLS response time within four minutes, and an ALS response time within eight minutes of an alert.(3)

To adequately provide EMS for the Indianapolis 500—the largest single-day, single-venue sporting event in the world(4)—we’ve developed a multifaceted approach. The most visible component of the medical division is the Clarian Emergency Medical Center, an infield hospital that’s approximately 6,000 square feet and divided into driver care and spectator care areas, with separate entrances to provide drivers with privacy and security from onlookers.

Four driver beds are equipped for hemodynamic monitoring in an area suitable for trauma resuscitation, and 14 additional beds are capable of hemodynamic monitoring of spectators. A broad array of emergency care equipment is available to treat any expected patient condition. Equipment includes general X-ray, ALS monitor/defibrillators, AEDs, cardiographs and vital sign monitors.

The infield hospital is complemented by 14 first aid stations strategically located around the IMS grounds, 19 ALS ambulances for response to spectator locations, six track surface ambulances, seven golf cart ambulances, eight paramedic teams on foot and two pit medic teams. All ambulances and roving medic teams are tracked from the communications room in the infield hospital, which also communicates with a local emergency department and trauma center so that we can send patients direct to the cath lab and alert the trauma center when an injured driver is en route.

The infield hospital is staffed with the medical director, between six and 10 emergency medicine physicians (depending on track activity), up to 15 registered nurses and an optometrist. All first-aid stations are equipped with AEDs and staffed by medics. All patients are brought initially to the infield hospital.

Although there are typically in excess of 1,200 patient encounters during the 12-hour period during which the track is open on race day, the overwhelming majority are for minor conditions that are easily managed on site, including minor abrasions, sprains, sunburns, nausea and dehydration. This past year, only 26 patients were transported off site, thereby limiting the impact on the local hospitals, although we do have mutual aid plans in place to deal with surge capacity.

Conclusion
Although the Indianapolis 500 is unique in the number of spectators and the size of the venue, almost every community faces the challenges of providing EMS during mass-gathering events, including sports events, concerts, political rallies, parades and fairs. Proper planning and preparation for mass-gathering events is critical to ensuring the safety and well-being of attendees and participants while ensuring EMS is prepared for the potential surge in patient care requirements.

Disclosure: The author has received no monetary support from Philips. The Indianapolis Motor Speedway has received support from Philips in the form of funding for evaluation and research purposes.

References

1. Indianapolis Motor Speedway FAQs. www.indianapolismotor speedway.com/about/35550-FAQ. Retrieved Aug. 4, 2010.
2. Arbon P. Mass-gathering medicine: A review of the evidence and future direction for research. Prehospital and Disaster Medicine. 2007:2(2);131–135.
3. Baez A, Sztajnkrycer M: Basic Principles of Mass Gathering Medical Care. Supercourse Lectures #17951.
4. IMS Public and Media Relations Department.

This article originally appeared in an editorial supplement to the September 2010 JEMS as “EMS in the Fast Lane: Mass-gathering medicine at the Indianapolis Motor Speedway.”



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