Major Incidents, Operations

Pearls and Pitfalls of Managing EMS at Mass Gatherings

Issue 5 and Volume 42.

The local arena contacts your agency to request coverage for an upcoming event to be held on Fourth of July. As the director, you must decide how to plan for this coverage. What type of event is this? How many will be attending? Will there be alcohol?

All these questions and more need to be answered in order to staff your event at a safe level for not only the possible patients but also the providers. Staffing the event is just the beginning. Your agency must be prepared for a dynamic environment that could be so uneventful it might nearly lull you to sleep but could quickly become so overwhelming where patient care becomes a real concern.

Vanderbilt LifeFlight Event Medicine (LFEM), associated with Vanderbilt University Medical Center, a large urban academic medical center in Nashville, Tenn., began operating in October 2008 with 10 employees and a single ambulance. Today, LFEM employs over 70 part-time employees including advanced EMTs, paramedics, and registered nurses. LFEM maintains a fleet of eight ambulances, several special rescue vehicles and bicycles, and a fully functional communications bus complete with Wi-Fi and aerial cameras.

LFEM staffed a record 750 events in 2015 and has covered more than 6,000 events since the genesis of the program. The agency served more than 4.8 million spectators in 2015 at venues that include two NCAA universities, a top 15 world-ranked arena, a semipro baseball stadium, as well as large outdoor events in our area such as Steeplechase, CMA Fest, and the Bashes on Broadway for New Year’s Eve and Fourth of July.

For the past three years, the program has had an increase in transports of at least 20% each year. Due to the rapid expansion of the program, LFEM has had to consistently evaluate and adapt to the environments we work in. This continual review and improvement allows us to meet the demands of the department and more importantly allows our agency to provide the most optimal patient care.


Consider the environment and topography when selecting
response vehicle types. Photo courtesy Warne Riker

The goals when providing medical care at a mass gathering event include rapid access to and care for the ill or injured; appropriate triage, treatment, and transport of those patients; and the provision of onsite care for minor illnesses or injuries.

Providing this coverage frees up local EMS to continue to function in the community and not divert resources to a large event.

The National Association of EMS Physicians describes 15 components to consider in a medical action plan for a mass gathering event.1 This article will take a closer look at a few of those components and the challenges LFEM encountered over the last eight years. It will offer readers insight into ways in which event medicine programs can better meet the needs of an event medicine program and the patrons they serve.

Staffing

The first priority as with any other mission is deciding how to staff the event. Literature regarding this is limited, however very consistent. The director should first try and estimate the need. This can be expressed in patient presentation rate (PPR), medical usage rate (MUR), or however your agency decides to approach this issue.2 Essentially, the director needs to consider how many people the staff might see and of those how many could possibly need transport. This can be done with relative accuracy by considering several known factors.

These factors include weather, expected number in attendance, presence of alcohol and drugs, expected age of crowd, if the event is bounded or unbounded, and the intent of the crowd.3

Studies indicate that rainfall and heat individually increase illness and injury rates.2 However, if the event is inside these variables would become less significant.

Attendance is a variable that could be weighed differently depending on type of event.2 Consider that 15,000 patrons attending a quilting conference would likely be more benign than 8,000 attending some type of electronic dance music (EDM) concert. Where attendance becomes more of an issue is when you compare the attendance in similar events.

For example, when comparing two separate EDM concerts where alcohol and drugs are widespread, we’ve seen a direct relationship with increase in incidents with increase in attendance. It can be incredibly valuable to review the numbers and types of patient encounters for a given event that’s been held in the past.

Generally speaking, studies indicate that attendance is the least predictable variable when estimating MUR and PPR.2 Although it’s difficult to predict MUR/PPR with a single variable, a combination of variables is where the staffing recipe can be found.

A little psychology 101 can assist the director when considering the age of the crowd. The younger crowds, who typically don’t seek out medical help on a routine basis, will often be seen at an event due to consequences of poor choices. On the other hand, older crowds, who do seek out medical help frequently, bring with them to the event their chronic conditions as well as the possibility of the environment exacerbating an existing controlled condition.2

Finally, and arguably the single most influential variable is the crowd’s intent. First you must consider the type of event you are staffing. Will the crowd be mobile (e.g., marathons or obstacle courses)? If they’ll be inside, will there be reserved seating or general admission with a mosh pit? It will only take about two hours into your first general admission concert with a mosh pit to realize you may have made a staffing error.


Although it’s optimal for the venue to have fixed first aid facilities, alternate arrangements,
such as an acute care tent, can be made as needed. Photo courtesy Linda Pierce

Logistics

Once staffing has been agreed on, the next step is preparing the gear and equipment the staff will need for a successful event. Things to consider include strategic placement of automated external defibrillators (AEDs), number of transport units needed, and if there should be fixed facilities (e.g., first aid rooms or tents) or roaming staff with appropriate equipment.

You can help improve public relations for your program by providing comfort and prevention items for the crowd, which could include sunscreen, misting fans, water stations and possibly even a limited supply of over-the-counter medications.

You must assure rapid response to a cardiac arrest. AEDs should be plentiful and placed evenly throughout the area included in your event space so as to allow for rapid defibrillation when appropriate. If possible, they should be in every tent and special rescue vehicle, as well as in the packs of roamers in each zone.

It’s optimal for the venue to have fixed first aid facilities. If the space doesn’t have existing first aid facilities, or the event is outside, preparations should be made for a space large enough to accommodate staff, equipment, and a small area for triage, staging and rehab.

The most cost-efficient devices are tents. They can range from larger ones for your main treatment areas down to smaller pop-ups in your more remote areas depending on the size of the event footprint.

Depending on the event type, roamers may need communication aides, bicycles, Segways or other off-road rescue type vehicles, and copies of general event information such as a venue map. Roamers must familiarize themselves with areas being covered. Most calls come in with vague location descriptions, such as “Riverfront stage by the lemonade stand.” That may be specific for the person reporting the call, but then consider that there are four lemonade stands in the Riverfront stage area.

It can be helpful to predetermine and name ingress and egress points throughout the venue so all responders are speaking a similar language.

Response vehicle types should be selected based on their appropriateness for the environment. Utility task vehicles (e.g., Gator) are fairly useful depending on the crowd size. If the space is mostly sidewalks and grass, however, it may be easier to move with bicycles or Segways.

Prior to crowd entry, the teams should take time to survey the area and plan for ways to extricate patients from problem areas. Remember to take into account the space and equipment needed to move someone in arrest versus assisting an ambulatory patient to the tent to cool down.

Consideration should also be given to medical facilities surrounding your event. Will the facilities near you be able to effectively treat the patients you anticipate transporting?

Transport plans should be discussed ahead of time including special circumstances such as the Level 1 trauma patient or critically ill pediatric patient who needs to be transported to an appropriate facility two hours away.

Communications

Communications for event medicine are very different than operating out of your unit or station. Although most in EMS are used to occasional lapses in radio etiquette, having 20,000 people around you can muffle even the best communicators’ radio transmissions.

Communication is arguably the most important part of delivering good medical care at large events and likely the most vulnerable part of a medical plan.

LFEM has spent a great deal of time adapting and enhancing our communication platform. We utilize an onsite communicator at most large events. This communicator is separated from treatment areas when possible, hopefully somewhere quiet. Ear plugs and noise cancelling headsets for care providers are a priority in loud environments. Without the right equipment, it’s possible the crew won’t even hear the call go out to begin with.4

Training, or maybe a better term would be practice, should be encouraged to perfect transmissions to the communicator in these environments.3 A common error is yelling into the microphone in effort to overpower the crowd, however this often causes the transmission to be garbled. Speaking calmly with an assertive tone is a best practice.

Plain language is the preferred method of communication via radio.3 Staff may be made up from different agencies that utilize different codes, and plain language alleviates
any confusion.

Roamers should take extra care in being specific in their communications. It’s important that other crews know where you are and what equipment you may need. Your team won’t have an address to respond to, so it’s up to the person on scene to give an accurate description of his or her location and any or all resources needed.

All communication needs should be met and discussed during pre-brief with the opportunity to address concerns or improvements in a post-brief. The communicator should have the equipment and facilities to log all activity as well. If possible, tracking times similar to those used in traditional ground EMS is helpful (e.g., dispatch time, on scene time, etc.).

Communicating with local hospitals is also critically important. Not only is it important to know what abilities local hospitals have when transporting, but it’s equally important to keep them aware of incoming patients to avoid overloading one facility.4

Communicating with intended facilities prior to a large event will allow the facility to prepare ahead of time. Some facilities may choose to increase staff and physician presence in an attempt to be prepared for a large influx of patients and to speed up patient flow as to allow for more bed space throughout the event.

Communicating with local EMS is also vital. There should be clear understanding of what level of care will be provided on site and also if there will be on site transportation resources.

It’s common for eventgoers to call 9-1-1 from cellphones when they need care. Open lines of communication will allow local PSAP’s to re-route that call to onsite communicators when possible so as to not delay response.

Finally, it’s helpful to debrief with event planners after an event. This should be done when the event is still fresh in people’s minds and will allow for improvements when like events are covered in the future.


Consideration should be given to how you’ll handle patients who
are intoxicated but may not need transport or are refusing transport.

Patient Flow

Patient flow begins with the dispatch of the call. Roamers must be familiar with the footprint of the event or the building. If the call is on third level of the arena in the middle of the top row, the roamer could be delaying patient care for valuable minutes if he responds without a way to safely move the patient from their seat to the waiting cot on the concourse.

Staff must be able to assess the patient in a timely manner and decide if the patient needs immediate transport or simply needs to be evaluated in a more controlled environment.

Patients who may benefit from being treated on scene and monitored for improvement are patients that are overheated. Actively cooling these patients and possibly fluid replacement can turn most of these patients around rather quickly and prevent transport. It helps when there is a higher-level provider on scene such as a nurse practitioner or physician to assist in making the transport/non-transport decisions and with treat and release.

On the other side of the equation, stopping to use fixed treatment facilities shouldn’t delay acute care and transport of a critical patient.4 Possibly the most important aspect of flow is the consistency of care. No matter the makeup of the event medicine team, all providers should be knowledgeable of protocols and trained to deliver the same care within their defined scope of practice. Patient hand-offs from roamers to transport crews should be just as clear and concise as bedside transfers at the ED. It’s important that the patient receives continued and appropriate care without lapses.

Event medicine crews should remain aware that they’re not only there for the patient’s well-being, but they’re also providing customer service. Efforts should be made to safely cater to patients as long as they have the capacity to make their own decisions. Keeping in mind the safety and best interest of the patients, crews should consider trying to limit disturbances to others attending the event.


Speaking calmly and in plain language, with extra care in being specific in communications,
is critical to successful communication at large events. Photo courtesy Warne Riker

When possible, patients should be evaluated and treated in areas that are the least distracting to artists and/or other event goers. Patient privacy should also be considered.

Documentation

All providers should know the importance of documentation. We’ve all heard the phrase, “if it’s not in the report it didn’t happen.” Just as it is when running calls, it is extremely important to be vigilant in your event medicine documentation.

Crews should be well-informed and trained to know what’s expected of them as it pertains to documentation. Given the volume of patient contacts, it’s easy to become lackadaisical in charting. First, we must define who’s a patient and who’s not.4 The right type of concert on Saturday night could have you in the same building with 15,000 altered mental status patients. Obviously, it’s neither necessary nor feasible to transport 15,000 people, so your department needs to have a plan you can depend on when covering these types of events.4


Remember to be systematic in your planning. And if you have difficulty
getting the information you need, it can often help to contact venues
that have had similar events and base your planning on their experience.

Consideration should be given to how you’ll handle patients who are intoxicated but may not need transport or are refusing transport. It’s helpful to create policies, with support from your legal department, pertaining to documentation and release criteria for these patients. The purpose of the refusal criteria is to put patient safety at the forefront while simultaneously attempting to protect the provider and program in the case of litigation. Although not an exhaustive list, below are criteria to consider for releasing intoxicated patients:

1. Patient must not be a minor;

2. No evidence of trauma exists;

3. The patient is not actively vomiting;

4. The patient is ambulatory without assistance;

5. The patient can be released into a responsible person’s care; and

6. There’s no other condition that would necessitate transport.

All of this should be documented on a refusal along with vital signs and any other assessment completed. Signatures from both the patient and a responsible party are required. If the event medicine program doesn’t have standard criteria, then a conversation with medical control would be the next best course of action when obtaining refusals for this particular type of patient. Patients often don’t want to be transported from an event so it’s critically important to have sound refusal guidelines and to continuously review refusal documentation so as to identify opportunities for continued quality improvement.

It’s important for the transport team to be as thorough as possible from the onset of injury. The final medical record should be able to be read from the time of onset and first person on scene to the bedside report and transfer of care at the hospital. This may require a synopsis of care given prior to transport crew arrival such as that received from the roamer on scene.


Pre-briefings are useful to discuss communication needs
during the event. Photo courtesy Jerry Jones

Conclusion

Patrons rarely attend events with anticipation of having a medical emergency, and they deserve the same level of care they’d normally be provided should they call 9-1-1 in the community setting.4 It’s the event medicine program’s responsibility to make that happen. Crews should be large enough and be equipped appropriately to handle the planned and unplanned emergencies in a time comparable to 9-1-1 responses.

As the need for event medicine continues to grow, the amount of associated literature is sure to follow. Remember to be systematic in your planning. If you have difficulty getting the information you need, it can often help to contact venues that have had similar events and base your planning on their experience. Use the resources you have to rate the variables we’ve defined: weather, expected number in attendance, presence of alcohol/drugs, expected age of crowd, and the intent of the crowd.

References

1. Jaslow D, Yancy A 2nd, Milsten A. Mass gathering medical care. Prehosp Emerg Care. 2000;4(4):359-360.

2. Moore R, Williamson K, Sochor M, et al. Large-event medicine: Event characteristics impacting medical need. Am J Emerg Med. 2011;29(9):1217-1221.

3. Hartman N, Williamson A, Sojka B, et al. Predicting resource use at mass gatherings using a simplified stratification scoring model. Am J Emerg Med. 2009;27(3):337-343.

4. Grange J. Planning for large events. Curr Sports Med Rep. 2002;1(3):156-161.