EDMG541

Koenig_and_Schultz_s_Disaster_Medicine_Ch_17.pdf

Management of Mass Gatherings

Michael S. Molloy, Zane Sherif, Stan Natin, and John McDonnell

Some people think football is a matter of life and death. I don’t like that attitude. I can assure them it is much more serious than that.

Bill Shankly, Liverpool Football Club Manager, In Sunday Times (UK) 1981

OVER V IEW

Introduction

Globally, the management of mass gatherings encompasses a wide range of activities because of varying types of events and baseline medical and health infrastructures. Mass gathering med- ical care can be challenging because it is provided in unfamiliar environments without access to standard hospital resources.

The material in this chapter will assist Event Medical Officers/ Command Physicians/Medical Directors, team physicians, and other medical and health personnel to plan for and provide medical services at mass gatherings. In many countries routine prehospital care is the domain of emergency medical technicians and paramedics. In others there is a mixed model with physi- cian involvement and occasionally physician direction. Although nomenclature is inconsistent across countries, this chapter will use the term “medical director” to denote the physician in charge of medical management at a mass gathering. Mass gathering medicine involves a spectrum ranging from additional prehos- pital resources being directed to a specific area for a defined time period to more sophisticated models in which resources remain in place over a prolonged time. This can include temporary field hospitals and the conversion of fixed facilities into sites where many medical, nursing, and paramedical staff provide care for one hundred thousand or more persons for periods lasting from 6 hours to 4 weeks.

In addition to the medical director, community public health plays an important role in mass gathering medicine, for example, sanitation, water supply, and food safety. In 2004 Levett described the growing awareness of public health issues that had developed in the Olympic time frame between the Atlanta and Sydney games.1 He noted, “prevention and preparation more than

ever are necessary for organized society, and effective planning demonstrates that future uncertainty can be reduced.” He fur- ther stated that public health should be an integral part of the planning process for the Athens games and that a dual strategy of supporting a successful event and also improving the quality of life of the Greek population would be desirable.

Emergency physicians are ideally trained to provide direct services at mass gatherings and also to provide leadership in planning the organization of routine medical care and poten- tial disaster response to these events. The American College of Emergency Physicians (ACEP) published a position paper in 1976 on the role of emergency physicians in mass casualty/ disaster management, recognizing that their training prepares them for these unique roles.2 In 1998 the Council of the Euro- pean Society for Emergency Medicine suggested, “specific train- ing in preparedness for disasters is required for all emergency physicians” and that members of the specialty should participate in disaster planning at local, regional, national, and interna- tional levels.3 Mass gatherings are in essence a form of orga- nized potential disasters in that a large group of patrons are in a defined area where an adverse event would affect a signifi- cant number of attendees and require activation of the region’s emergency management plan. Because mass gatherings occur sporadically, they are not routinely included in local authority or regional disaster plans. Event-specific planning and appro- priate training at the local and regional levels are important. Hsu, in a review of the effectiveness of mass casualty incident training, highlighted that preparedness at the hospital level has increased; however, the effectiveness of training still requires evaluation.4

The mass gathering event site may be a temporary facility or a modified fixed facility where the standard emergency plan is insufficient. The standard event plan focuses on event logistics and not on managing a major incident. For this reason planned mass gatherings should have emergency management plans of their own separate from the event plan. Mass gathering medical care is likely to become increasingly important in the current world climate as governments and other statutory authorities place more emphasis on emergency planning.

228 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:38:34.

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MA NAG E M E N T O F MA S S GAT H E R I N G S ■ 229

Medical textbooks that describe illnesses and novel treat- ments generally transcend borders and will provide useful information for clinicians treating patients irrespective of their locations. Conversely, although basic principles apply globally, mass gathering medicine varies according to applicable laws and variable health systems. In a career focus article in the BMJ, Hearns outlines the qualities, training, and benefits associated with event medicine or mass gathering medical care.5 Many physicians provide mass gathering medical care on a voluntary basis for sports clubs or societies for which they are also the team physician, thereby mixing roles. Some sport rules specify that there be a physician present prior to the game starting, others specify that there must be a separate “crowd” doctor in addition to the team physician when the crowd is over a cer- tain size. Whether the physician is paid or acting as a volunteer does not change the “duty to care” or “standard of care” for the patients. Physicians must be appropriately trained prior to serv- ing as medical directors for mass gatherings. The Gibson report in the United Kingdom published in 1990 made recommendations about medical care at football matches. Gibson emphasized that the specific requirements should include communication skills and command and control procedure training for major inci- dent management. In the British Journal of Sports Medicine in 1999, Kerr noted that 9 years after the Gibson report was pub- lished, 44% of doctors providing medical services at sports events remained unaware of the major incident plan for their stadium.6

Nearly three-quarters (72%) of the doctors Kerr questioned had received no training in major incident management and 61% indicated they had not attended Advanced Cardiac Life Sup- port (ACLS)/Advanced Trauma Life Support (ATLS)/Pediatric Advanced Life Support or other British Association for Imme- diate Care (BASICS) resuscitation courses. These results are for a country that has placed considerable emphasis on major inci- dent training and mass gathering medical care as a result of foot- ball match incidents and therefore may underestimate training deficits in other countries.

Some events that should be considered “mass gatherings” for the purposes of medical management have not traditionally been considered as such. For example, certain religious events are some of the biggest regular mass gatherings, such as the papal gather- ings for the Catholic church and the Hajj for Muslims.7–11 It is not unusual for half a million people or more to participate in papal gatherings. Medical planners may underestimate the numbers who will require medical attention at such events.12 In a descrip- tive study of the 1982 papal visit to Coventry, Avery suggests that for any gathering of up to 350,000 people significant planning will be required.7 Earlier, in 1979 Pope John Paul II held a papal audi- ence in Phoenix Park, Dublin, Ireland that was attended by more than 1 million people (approximately one third of the popula- tion), one of the highest percentages of a nation’s population in attendance in a confined area for a single event. Although 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. Up to 2 million persons participate annually and there are excel- lent data on the various medical aspects of the pilgrims and the additional impact on hospital admissions during the Hajj.11,13,14

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.

Definition

There is no standard definition of a mass gathering. In addition, mass gathering medical management has only recently received attention, possibly because physicians have not historically had full time roles. Ordinances dating from 1974 in North Carolina, U.S. 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.15

To provide for the protection of public health, property, pub- lic welfare, and safety the Union County Board of Commis- sioners, North Carolina adopted ordinances that 1) define mass gatherings and specify that permits are required; 2) specify cre- ation of detailed maps showing the general location, emergency ingress and egress routes, and emergency medical facilities; and 3) mandate services need to 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 contem- plation of profit, of more than 200 people in an open space, or open air for a continuous period of at least six hours.

Alleghany County, also in North Carolina, enacted similar ordi- nances in 1975 that increased the number of people required to define a mass gathering to 300.16 The Arkansas State Board of Health also within the United States defined 1,000 persons in one place for more than 12 hours as a mass gathering.17 Most authors when discussing mass gatherings in a modern setting refer to gatherings of more than 1,000 people, although others define a mass gathering as being greater than 25,000 persons.18,19

In determining the types and amount of medical care that should be available on site, important elements to consider include dura- tion of the event, spectator type, participant size, demographics, geographies, and access to definitive medical care. In 1999, Jaslow published a review of U.S. state legislation and found that only six states had specific emergency medical services (EMS) legislation governing mass gathering medical care, namely Connecticut, Iowa, New York, Oregon, Pennsylvania, and Wisconsin.20

For this chapter a mass gathering will be defined as an event that requires special planning to ensure capacity and capability for the provision of appropriate medical care to attendees without adversely affecting medical care in the host community. The na- ture of the event including its size and duration, the numbers and demographics of participants, and its geographical 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 com- munity. Medical resources must be planned to mitigate any

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:38:34.

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230 ■ MI C H A E L S. MO L LOY, ZA N E SH E R I F, STA N NAT I N, A N D JO H N MCD O N N E L L

Figure 17.1. Mass gathering classification scheme as proposed by Molloy.

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 lan- guage 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 (Figure 17.1).

Some mass gatherings reduce emergency department (ED) visits, probably due to spectators remaining in their homes watching the event on television.21,22 Events that are recurring (e.g., local annual fairs, the Hajj) yield historical data that can be used for planning future iterations. Planners can estimate resource needs for major sports events such as American football, NASCAR, baseball, golf, rugby, or soccer that recur regularly in the same location.23–27 Team members should be cross-trained so that they can fill alternate roles if necessary (e.g., adminis- trative roles if the regular director and deputy are unavailable). Using the same team for each recurrence of the event reduces training requirements.

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 such frequent events is that they can lead to complacency. A varied training pro- gram emphasizing elements of trauma, cardiac, pediatric, major

incident care, and specific hazards will help mass gathering staff to remain vigilant to potential threats.

History of Mass Gathering Medicine

Mass gathering medicine is a relatively new concept. The first mention in the U.K. literature was a short piece entitled the “Price of Pop” in the Lancet in 1971.28 The author describes the effect of a pop festival on a small island community with a population of approximately 120,000. Attendance at the festival was estimated to be 250,000 people at maximum. This temporarily more than doubled the population, created traffic, noise, feeding, and san- itation problems. The authors suggest

Open-air pop festivals lasting two or three days may be a passing phase, but other fashions may encourage similar gatherings and conditions.

Mass gatherings have grown in frequency and size since this initial description.

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 Nebraska, organizers instituted a system whereby staff and equipment were strategically placed within the stadium ready to respond to emer- gencies.29 As a result of historic disasters, in the United Kingdom and Ireland, procedures for treating urgent casualties have been in place for almost a century in many sports venues (Figure 17.2).

Figure 17.2. Deaths in U.K. football stadia.

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MA NAG E M E N T O F MA S S GAT H E R I N G S ■ 231

Initially the focus was on protecting participants rather than spectators. In the 1960s disaster planners created the forerunner to the U.K. BASICS with the goal to provide medical assistance to ambulance services at scenes of localized emergencies or major incidents such as mass casualty events. In 1977 healthcare lead- ers founded BASICS, a system that provides regional teams to respond to disasters throughout the United Kingdom.30 Many of its members provide mass gathering medical care at stadia.

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 semifinal a large gate had to be opened to allow late comers entrance.31 This resulted in a rapid build up of supporters on a terrace that was already crowded. There was no escape at the front because of a crowd control ring fence. Large numbers of the crowd suffered asphyxia.32,33 Ninety-six people lost their lives, 81 on site and 15 more subsequently in the hospital.34 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: 81 patients were subsequently admitted to the hospital. DeAngeles described a similar incident in the United States that resulted in 80 persons being injured by crushing or trampling during a crowd surge at a college football game.35 On this occasion 86 people were transported to the hospital, 10 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 dis- aster in 1985 resulting from a flash fire that consumed one side of the Valley Parade football stadium in Bradford, England. The fire engulfed old wooden stands in less than 4 minutes and 53 people died with more than 250 additional people injured.36–38

Some of the crowd were so badly burned that they could only be identified from dental records as described.39 Sharpe in 1985 wrote about the treatment and triage of multiple burns vic- tims arriving almost simultaneously at the local hospital and the sequence of internal coincidences that ultimately minimized the consequences.40 He subsequently coined the mnemonic COMMUNICATION to help educate other plastic surgeons who may be faced with a similar mass gathering disaster.41

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.

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 (Figure 17.3). 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 in 1982 when dozens of sport spectators were crushed to death in Moscow, the true magnitude of the disaster did not become evident until many years later, even to those on site. Morbidity and mortality num- bers have been substantial and have prompted major changes in the way events are planned and organized. Some of these disasters have occurred in older stadia where walls, ceilings, or roofs have collapsed. Football authorities have instituted a team licensing system to help prevent this from recurring.

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 (Fig- ure 17.3).

Types and Sites of Mass Gathering Events

I went to a fight the other night, and a hockey game broke out.

Rodney Dangerfield

Mass gathering events may take many formats. Researchers have described event-specific aspects of medical care for the following

■ Local fairs42

■ Music events28,43–50

■ School and university gatherings51

■ Stadium sports events6,52–56

■ Summer and winter Olympics57–60

■ Major football championships (World Cup, Union of European Football Associations [UEFA] Champion- ship)6,27,40,61,62

■ Marathons63

■ Rugby and cricket world cups ■ Motor sports25,64

■ Water sports ■ Political demonstrations42,65

■ Religious events7,9,66

Modern arenas or stadia are equipped with medical facilities built to be compliant with community health and safety standards. In many countries local governments build municipal stadia that are licensed to various sporting bodies to use for their particular events. These stadia are frequently used to host rock concerts and some religious gatherings. Because they are designed as multi- purpose stadia there are standard basic medical kits and facilities. For contact sporting events, large rock concerts, or long-duration mass gatherings, additional temporary facilities generally need to be constructed to meet the increased medical and health needs.63

Figure 17.4 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 “back stage”

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Figure 17.3. Deaths and injuries during international football disasters.

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.

UEFA, the European football regulatory authority, has requirements specifying what facilities must exist for clubs to be licensed to compete nationally and throughout Europe, such as in the Champions league. These regulations are available at UEFA.com or from the national football governing body of the specific country.67 More commonly, a large event takes place in a venue without planned medical facilities and these will have to be created de novo (Figure 17.5).

Figure 17.5 shows an aerial view of Slane Castle, the site of the U2 homecoming concert in 2001 and also the qualify- ing event for the 2002 World Cup soccer game. 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 is 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 km-long queue of people outside the stadium waiting for gates to open. The castle itself is in the midground and has been site to many of Ireland’s most memorable rock concerts since 1981. Evident in the photograph is the natural slope from

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Figure 17.4. Killarney GAA Stadium: Summerfest 2006 credit: macmonagle.com.

entrance on the road to the river more than 150 m gradient below. This particular slope can result in significant numbers of trau- matic injuries on challenging underfoot conditions in inclement weather. Murphy described the effects on regional hospitals after an event when 88 patients presented to the two local emergency departments with 13 fractures, six requiring manipulation after induction of anesthesia or formal open reduction and internal fixation.68 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 there are more than 84,000 people in a very con- fined space with identifiable access and egress routes. Thus, crowd density would be another potential hazard. This example illus- trates the types of challenges that are encountered globally due to geography, topography, and insufficient local medical infra- structure.

Tuas maith, leath na hoibre An old Irish phrase meaning a good start is half the work.

CURRENT STATE OF THE ART

Mass Gathering Event Planning

International guidelines for mass gathering event planning are lacking. Countries with well-developed emergency medical sys- tems such as the United States and the United Kingdom 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 fre- quency.54 An ad hoc request the evening before an event indi- cating “the need for a doctor for insurance purposes” leaves the physician unprepared. This may be the first time the physician will have been asked to provide medical services and there may

Figure 17.5. Slane Castle 2001: U2 concert.

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be no information provided on the layout of the venue, the size of the crowd or number of event employees, what medical facil- ities will be present, or the standard of training and degree of equipment carried by the EMS service (which may be a volun- tary provider) on the day. Other important elements to know in advance include historical information such as how many patrons needed medical attention, have there been any fatalities, what were the crowd demographics, and how many patients were transferred to hospitals?69–73

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 of that size and how many would be on call at any specific time. The U.K. Event Safety Guide has staffing guidelines.74 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. For example, if 14 physicians are required on site at all times and they rotate in 12-hour shifts, a total of 28 physicians per day must be rostered. 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 that should be involved early in the planning process include but are not limited to those named in Table 17.1. 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 circum- stances. In 1996, the ACEP EMS Committee produced guidelines for the provision of emergency medical care for crowds.75 These can be applied in most countries. The National Association of EMS Physicians (NAEMSP) also promulgated guidelines.76 One key NAEMSP planning document is Jaslow’s Medical Directors checklist.77

Event-planning Timeline

Local Planning Authority Plans are only good intentions unless they immediately degenerate into hard work.

Peter Drucker (1909–2005)

Calabro and colleagues produced a precise event-planning sched- ule for ACEP in Provision of Emergency Medical Care for Crowds.75 A sample event timeline modified for Ireland is shown in Figure 17.6. A new template is used for each event and plan- ners provide periodic reports to the director. To allow flexibility to account 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.

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 biweekly football games, planning may

Table 17.1: 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

become routine. The event-planning timetable for such regu- lar mass gathering events can be further modified by designat- ing 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 time scale for the others. For regular events, a yearlong time scale 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 plan- ning stages, compress time scales, 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 con- suming 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.

Modified from Provision of Emergency Medical Care for Crowds, American College of Emergency Physicians.75

The following section provides additional detail for each step in event planning as outlined in Figure 17.6. Define event including

■ Agencies involved ■ Type of event ■ Duration ■ Dry or wet event (alcohol or not), age policy for alcohol sale ■ Screening for drugs at entrances ■ Attendance levels ■ Demographics of attendees (minors admitted? elderly or dis-

abled expected?) ■ Expected transport modes of 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

■ Identify topography ■ Estimate site diameters/circumference

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MA NAG E M E N T O F MA S S GAT H E R I N G S ■ 235

Figure 17.6. Event-planning schedule.

■ Plan location of access/egress routes (use Google Earth or equivalent for aerial maps)

■ Identify likely location of main and secondary stages for multistage events

■ Based on above, plan location for first aid posts and on-site hospitals

■ Identify potential hazards and mitigate them ■ Identify likely location of campsites if applicable ■ Repeat site visit during adverse weather conditions

Event-planning Meetings/Get Site Plans Regular meetings will take place prior to the event. Some enti-

ties like the local emergency planning unit, government health service, and fire and police services will assign a full-time per- son 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.

Early review of the event site plan allows an analysis of the potential roles for existing medical facilities and ambulance ser- vices. 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 resources that may be more convenient for existing entities.

Designate and Agree on Responsibilities ■ Traffic management ■ Site management ■ Health and safety ■ Voluntary aid ■ Communications

■ Transport to site ■ Transport within site ■ Campsite (if present)

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 pro- cess 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 organiza- tions prior to the event to determine their roles, duties, respon- sibilities, and reporting relationships. Specific policies and pro- cedures requiring clarification include 1) Under what authority do accompanying physicians work? 2) Who is responsible for the medical actions of nonphysicians? and 3) If a major medical inci- dent 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. 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 inci- dent command system. For large events the administration sec- tion 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 is completed at all levels and that essential data are seamlessly

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communicated between various medical facilities. Patient track- ing is important and a system should be in place that enables workers to provide information to friends and relatives with 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, communi- cating with others who have managed similar events and obser- vation of the planning process if feasible 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 details of medical staff/event managers/safety

officers ■ Contact details of local hospitals/ambulance services ■ Event medical command structure ■ Proposed location of field hospital(s) and level of care to be

offered ■ Proposed location of satellite units and level of care to be

offered ■ Proposed location of ambulances and level of care to be

offered ■ Proposed location of staff facilities and parking facilities ■ Duties and responsibilities of medical staff ■ Duties and responsibilities of medical director/site medical

officer ■ Communications chain/structure/contact details/proced-

ures ■ Documentation and chain for documentation ■ Procedure for hospital referrals ■ Stand down (return to baseline operational level) details

Develop Site Emergency Plan The site emergency plan differs from the routine medical

plan in that this is the procedure to be followed in the event of a disaster. A standard agreed phrase should be determined that would communicate to all staff that an incident has occurred. Event staff should be prepared to accomplish the following 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

■ Major incident ■ Exact location

■ Type of incident ■ Hazards involved (if any) ■ Access to site ■ Number of casualties ■ Emergency services required

■ Log events carefully ■ Identify resource requirements

Liaise with Local Emergency Departments/Emergency Medical Services/Trauma Units

Many EMS systems have designated specialty receiving hos- pitals for patients meeting certain criteria, for example, trauma, burn, cardiac, and stroke centers. Protocols in other systems direct that patients be transported to the closest ED or to the hospital of patient choice. Advanced coordination with ambu- lance services and local emergency departments will help ensure integration with nonevent-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 be able to make an assessment of needed trans- port resources. Site visits to local ED leaders are also important to meet key personnel and understand respective responsibili- ties and resources prior to an event. Local hospitals may provide information critical to event planning.

Obtain 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 coverage for mass gathering events. In some countries physicians have malpractice insurance and 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.

Confirm Financial Arrangements/Attendance/Camping/ VIP Arrangements

Providing financial compensation for event workers will make recruitment easier. Budget calculations and work agree- ments must be prepared ahead of time.

Projected attendance estimates, including camping numbers, are necessary to determine medical workforce requirements. Staffing projections should account for changes in attendees over day of week and time of day (e.g., campsite overnight).

If significant numbers of VIPs 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 rock celebrities. Plans must be in place to manage illnesses and injuries if they occur among this group. This is par- ticularly 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

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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 portions of the healthcare system are not depleted so they can provide staff to the event site. If identified staff are not sufficiently trained and certified, the event medical director may need to arrange specific training for the event team. Depending on the jurisdiction hospital-based physicians may be required to obtain medical licensure for prehospital events. The director should consult with local medical licens- ing authorities to ensure that requirements are met in a timely manner.

Develop Medical Protocols and Standard Operating Procedures

The director, deputy, and medical team should develop, pub- lish, and distribute medical protocols for medical staff in advance of the event. Standard operating procedures should also be pro- mulgated for first aid and voluntary aid that delineate levels of care and when additional medical help should be requested.

Procure Clothing Safety clothing is essential for mass gathering events. Team

members should provide professional gear including safety boots, gloves, and high-visibility clothing. The event organiz- ers should provide event-specific items such as high-visibility vests/caps/light rain jackets and so forth. Logistical arrangements like sizing for all team members must be made in advance to ensure timely delivery of specific seasonally appropriate cloth- ing.

Procure Equipment The medical director should consult with staff who will be

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 develop a budget and make a request to the event organizer to provide funds for purchase or lease of the equipment for the duration of the event.

Generate Outline Rosters/Assign Roles/Procure Passes and Credentials

After calculating the expected number of attendees and the expected variations over time, staff scheduling by area should begin. The U.K. Event Safety Guide is a valuable resource for estimating staff requirements.74 Numbers of physicians needed on site will depend on the level of training 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 gather- ing events and will need to be collected 7 days in advance of the event to ensure distribution to individual team members (unless the team is traveling together to the venue). Identification should allow access to all areas. If team members are traveling separately they will need parking passes and route-access passes for any roads that are closed to the public.

Set Up Event/Begin Build/Check Medical Facilities The first phase of “set up” for the event begins 7 days prior

with staging equipment in containers that are ready to be moved on site. 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 secure them with a responsible worker at shift change. Most events start early in the morning. The medical team should be on site and prepared 2 hours before the event. 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 to the on-site team that includes information on

■ Use of radios and channel numbers for communications ■ Channels for 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 ■ Site of main medical facility and satellites ■ Break periods with meals

The briefing should also give instructions on procedures in the event of a disaster/major incident to include

■ Assembly point for retasking ■ Triage protocols ■ Communications channels ■ Roles of individual physicians and assigned posts

Debriefing Mass gathering medical care regulations vary by country and

individual locality. In Ireland and the United Kingdom legislation requires medical teams to remain on site at their posts for a minimum of 1 hour after the event has finished. For music events the end time would be when the band has left the stage whereas for sports events the event is defined to end when the teams have left the field. The intent of this requirement is to ensure that there is an appropriate level of medical care 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 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?

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■ 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 of the event 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 help- ful 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 to be addressed 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 food-borne pathogens should be sought and the public health services alerted in a timely fashion. In June 2008, the World Health Organization published a comprehensive “key considerations” document in relation to communicable diseases and response for mass gatherings detailing risk assessment and management, surveillance and alert systems, outbreak alert and response systems, and cross discipline considerations such as training, logistics, and communication systems.78

Break Down Event Break down procedures should mirror the set up phase.

Transport containers need to be repacked, inventoried, locked, and prepared for transport. A detailed inventory of stock used will assist with planning for similar events in the 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 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 to 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, additional medical posts may need to be established over night. Depending on the flow of patrons these posts may not be in operation during the day when few patrons are expected to remain on campsites.

Medical Reconnaissance

It is a bad plan that admits of no modification. Publilius Syrus (∼100 bc)

A site visit by the medical director and deputy can reveal a num- ber 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 Earth is a useful tool for generating aerial maps for the majority of locations worldwide. Maps can show access routes overlain with rail networks. It is useful to drive to the event

site during peak traffic to estimate transport times to the venue. Per licensing requirements, the event start 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 that may have been two-way may only be one-way. The medical direc- tor 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 would need to 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 and 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 hospital. The Event Safety Guide has a useful model for predicting resource requirements including a scoring system for proximity to definitive care.74

Planning should account for the fact that the 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 in a moderate-sized setting with an annual ED volume of approximately 36,000 (fewer than 100 patients per day), a requirement to transport 100 patients over a 24-hour period would likely exceed surge capacity in that institution. Nix and Ryan in their papers from Ireland in 2004 and 1992, respectively, describe the effect on attendances at local and regional emer- gency departments for a 3-day festival and a large single-day rock concert.47,79 In Nix’s case there were 1,355 attendances for medical attention on site over a 2-day festival (3 nights camp- ing on site). This represented 1.7% of those in attendance at the event. Milsten in 2003 discussing variables influencing medical usage rates (MURs) describes the term MUR as being a num- ber of presentations per 10,000 attendances.80 For the Nix event this would then result in an MUR of 171, a significant number when compared with 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 it was a much shorter event than Nix’s and resulted in only 18 patients being trans- ported. Nix reported 72 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 trans- fers that occurred from the local ED to a regional trauma center or for higher levels of care due to the need for intensive care services.

The numbers of physicians in the field at the event may be significantly more than that 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 ambulance 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 hos- pitals. In some settings, the local ED may also not be able 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

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described by Arbon is useful for repeat events.19 This complex model predicts the requirements for patient transports. Require- ments 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 needs to talk to the venue owner or facil- ity manager regarding the site itself, its current usage, drainage patterns, whether the fields have been rolled or not, internal access routes, and use of chemicals on the land. Rolled fields will help prevent ankle injuries. Facilities that have been sprayed with chemicals may result in allergic-type ophthalmological pre- sentations especially in summer. Hay fever exacerbations may increase in number when large open fields have recently been cut in advance of the event. Some facility managers may cover the playing surface in a stadium with a temporary surface to pro- tect 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.81

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 campsites; access routes and medical facilities should not be located there. Thousands of patrons could potentially be stranded when attempting to leave the event if parking is situated in an area prone to water logging. 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 transport between the clinical areas, around the circum- ference of the site, and between the campsites (if present) and the main arenas. In a football stadium this may be a simple task; how- ever, in a large open-site race course where there may be multiple venues and campsites accommodating more than 50,000 people, there may be a need for medical personnel to have on site trans- port. Such transport should be season and weather appropriate, for example, golf carts are unlikely to be useful in muddy, marshy conditions.

VIP care including access and evacuation plans needs to be discussed in the planning stages. At the time of this writing, Ire- land has the highest proportion of helicopters per capita in the world and these are used frequently for VIPs to attend mass gath- erings. The event medical plan should address potential hazards from helicopters if they are to be used. If the VIP area is distant from the on-site medical facility, a separate VIP medical area may need to be established.

Local authorities and law enforcement are good sources of information regarding the potential for violence or issues related to drugs misuse. They may require the presence of a physician at “pat down” entry to the venue to verify that tablets/medicine 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 referral process during the event. The local ED may be small and the addition of 80,000 event attendees may result in significant increases in atten- dances.47,68 In some areas there may be a local referral hospital, in others there may be protocols for bypassing local facilities and

transporting certain types of patients to specialty receiving hos- pitals such as trauma centers. On-site physicians must be familiar with these policies.

Negotiations

The medical director should ensure that negotiations take place at an early stage. Issues for discussion include

■ Liability coverage ■ Compensation ■ Site access ■ Required resources ■ Command and control issues ■ Safety ■ Communications ■ Transportation ■ Housing on site (if applicable) ■ Media issues ■ VIP medical care ■ Documentation ■ Postevent debriefing and reporting requirements

The medical director should negotiate compensation for all staff providing medical services and also appropriate compensation for the director and deputy for the planning, preparatory work, and medical direction during the event. Recruiting additional appropriately trained medical staff for the event will be easier if the compensation package is understood. In systems where mass gathering medical care is provided by the local health authority, hospital staff may be offered additional compensation to provide medical services to the event. This arrangement can be advan- tageous for the event organizer as many of the employment and liability issues will be covered by the hospital.

Site access will also need to be negotiated in advance. On large event sites, patron access levels vary from highly restric- tive to an “Access All Areas Pass.” Even the highest level of patron pass may not include access to certain secure areas of the site. Medical personnel should be granted access to all areas needed for responding to patient care needs, even if this includes the ability to traverse a restricted area. On-site security workers must be educated to allow healthcare workers access when they are responding to medical emergencies. Other important access issues are car parking and route access. If special venue route access passes exist, medical teams need them to ensure that they are able to transport medical equipment to the site.

A system of identifying medical, nursing, and paramedi- cal personnel is required and should be coordinated with other event workers. Identifying clothing such as polo shirts, T-shirts, sweatshirts, and rain jackets with pockets to store medical items should be provided. Team members should provide their own personal protective equipment such as safety boots, trousers, gloves, and high visibility jackets with appropriate identification for overnight work. Shift duration should be no longer than 12 hours for very high-intensity work or 16 hours for low-intensity work. For events that are multiple days in duration, on-site lodg- ing may be the most practical and time efficient arrangement for the team. This would reduce the risk of motor vehicle collisions driving home from the event late at night. For overnight work accommodation may also be required for on-call staff to allow for short rest periods and sleep if possible. Even small amounts of anchor sleep have been shown to improve performance.

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VIP medical care procedures need to be negotiated in advance. At some large events there is a specific VIP area that may be back stage or otherwise separated from the rest of the attendees. Placing a dedicated physician in this area may pre- vent problems related to patrons or the media trying to access the medical tent where a VIP is being treated. If the promoters request a separate physician dedicated to VIPs this should be added to the numbers required to staff the event itself as per the local template used to estimate staffing levels or the U.K. Event Safety Guide.74

Airway problems represent some of the most sensitive issues related to mass gathering medical care. Although anyone with emergency airway experience (e.g., an emergency physician) can fulfill the role of airway management, in some countries, event promoters often specify that an anesthesiologist be among the medical team in attendance. Staffing levels as suggested in the Event Safety Guide refer to the number of generic physicians required to staff an event in the United Kingdom.74 If physicians with specific training and experience are required, they should be in addition to the generic number of physicians calculated. The medical director, and deputy for large events, should focus on administrative aspects of event management and will therefore not be available to provide direct medical care.

On-site transport issues should be addressed during the advance negotiations. For bounded sports stadia and indoor venues it is unlikely that on-site transport will be required; how- ever, for large unbounded events on sites such as city parks, race courses, marathons, or music festivals with large campsites on- site transport is essential. With very large events promoters may have to identify a significant number of golf carts or quad bikes in advance. The medical director should ensure that adequate types and numbers of transportation vehicles are dedicated to medi- cal staff. Vehicle type should be appropriate to the terrain and weather conditions. Some event sites are only accessible by foot, for example, at the Glastonbury Festival of Contemporary Per- forming Arts in England, patrons hiked through mud baths every day to reach the concert venue from the campsite. For flat venues with long transport distances it may be necessary to secure carts that can accommodate spinal boards for transporting patients with suspected spinal injuries.

Level of Care

Level of care provided on site will depend on a number of factors including

■ Local legislation, ordinances, and licensing rules ■ Event size ■ Presence of on-site camping ■ Estimated effects on local EMS infrastructure ■ Whether the site is remote from local hospitals ■ Whether the local area is urban or rural ■ The capacity of the local ED to treat trauma patients and

admit intubated patients

Local designations of provider level may include emergency first responder, first aid personnel, and emergency medical techni- cian. Patients should be assessed by the most appropriate person based on their medical needs. In the setting of mass gatherings, significant numbers of internal transports of patients from satel- lite facilities to stations where there are nurses and physicians

or to the site hospital facility may be required. The level of care plan should address early defibrillation goals and how these will be achieved on a dispersed site. In generic terms the level of care provided should mimic what is available in the community and should not drain community resources needed for nonevent- related emergency care.

The level of care plan should address the ABCDEs of mass gathering management as follows

■ Airway – assessment of compromise and management ■ Allergic reactions/anaphylaxis/altered mental status ■ Breathing assessment and management ■ Bites/burns/bones/back pain ■ Circulatory problems – assessment and management, includ-

ing chest pain ■ Disability assessment – strokes, headaches ■ Drug ingestions/drug exposures/drug overdoses/diabetic

emergencies/drowning ■ Electrocution/environmental emergencies/eye and ear, nose,

and throat presentations ■ Soft tissue injuries/psychiatric emergencies/syncope/seiz-

ures/spinal assessments in trauma

Airway management is one of the issues of greatest concern for event promoters. The medical team on site at mass gatherings should be skilled in emergency airway management. All members of the medical team should be aware of the location of the nearest equipment (if it is not carried on the person). At least some types of rescue airway devices such as the bougie, laryngeal mask airway, intubating laryngeal mask airway, and Airtraq single-use intubation assistant should be available.82–84

Medical Oversight

The event plan, not the medical plan, defines requirements for medical oversight. In many jurisdictions, this is the document submitted for licensing or permits. It should contain specific roles and responsibilities for both the medical director and deputy and indicate which position will have the primary medical command officer role in the event of a major incident. The event plan may also specify the various training requirements, certifica- tions, and indemnity/malpractice or insurance required of the medical director and deputy. The medical team provides both indirect and direct medical control. The medical director’s indi- rect role refers to designing the site medical plan and ensuring that standardized levels of care are present throughout the site. There must also be a mechanism for medical supervision of all activity on site either directly in the same vicinity or indirectly by protocol or standard operating procedure.

Direct medical oversight refers to the director’s supervisory role during the event. The director should be easily recognizable by uniform. Jaslow outlines these roles in detail in the United States context in the Mass Gathering Medical Directors Care: The Medical Directors Checklist.77

Medical Staff Selection

Because significant orientation and training is necessary for per- sonnel without prior experience in mass gathering medicine, medical staff selection should take place as early as possible. On- site providers should not be given the false expectation that they

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will have the opportunity to enjoy a free sporting or music event. Rather, their primary mission will be to support medical care for the event.

The director should identify the numbers and types of staff needed, using appropriate tools. Depending on crowd numbers there may be a requirement for first aid or more advanced medical tents to be spread over a large area. Thus some practitioners will be expected to work alone at times and must know the indications and procedures for accessing more advanced medical care. If possible, staff recruitment should begin 1 year prior to the event, particularly in rural locations where resources may need to be drawn from outside the local area.

Medical Staff Training

All those providing medical care at the event should be qualified to provide appropriate levels of life support. A board-certified physician with regular experience during routine duties probably does not need additional clinical training but may need training in incident command systems. For certain levels of providers, additional certifications may be desirable or required. Depend- ing on roles and responsibilities, these could include Basic or Advanced Cardiac Life Support, ATLS, Prehospital Trauma Life Support, International Trauma Life Support, Advanced Disaster Life Support, Major Incident Medical Management and Sup- port (MIMMS), Safe Transport and Retrieval, Advanced Life Support in Obstetrics, Neonatal Resuscitation Program, Haz- ardous Incident Medical Management, and Advanced Pediatric Life Support.

Completion of the stadium or Advanced MIMMS courses is desirable for event medical directors. Advanced degree pro- grams (e.g., MSc, MPH, MBA, PhD) that focus on disaster and emergency management are becoming increasingly available and would be useful for physicians pursuing a career in this field. One unique program conceived in 1998 is the European Master in Dis- aster Medicine, a second-level masters degree awarded jointly by the Free University of Brussels and The University of Eastern Piedmont in Italy (http://www.dismedmaster.com/). This is a 1-year interactive distance-learning program in which students from around the world complete course work, online examina- tions, a publishable thesis and a concentrated 2-week residential program that includes a full-scale major disaster exercise.

The Royal College of Surgeons in Edinburgh, Scotland offers a diploma (DipIMC) and Fellowship examination (FIMC) in immediate medical care. The training provides a solid framework for medical practitioners and advanced paramedics in many of the skills needed for mass gathering medical care. Sporting bodies such as the Football Association in the United Kingdom spon- sor a course in rapid emergency management on field called REMO. The Football Association also offers a stadium manage- ment course, “Crowd Doctors Course” that addresses all aspects of crowd medical care. The Rugby Football League, based in Leeds, England provides a course entitled immediate medical management of the field of play designed for doctors who are providing medical care to teams and in stadia at rugby league events. Physicians providing on-field services to rugby league teams are mandated to be current in their certification or their team will face a hefty fine.

If the event is likely to recur, the director should consider developing a training schedule for a pool of dedicated staff. This can provide training opportunities in mass gathering medical

care for resident physicians and disaster medicine fellows, prac- tical experience as a team member, and the ability of those with an interest to train as a deputy medical director.

Triage

Triage has existed since the days of the Napoleonic wars as a method to ration medical resources when demand exceeds sup- ply (see Chapter 12). Most systems have an initial filter for ambulatory wounded patients (termed “minor” or “green”). The remaining patients are then categorized according to repro- ducible scales. Several dozen triage systems exist and use various tools, labels, and even colored hair bands or clothes pegs to sort patients in priority of either medical need or order for transport to definitive care sites. Separate systems exist for pediatric triage and should be considered if applicable to the event demograph- ics. Because few data exist that validate any of the multiple triage systems, choosing a system familiar to local providers may be the best option.

Medical staff at all levels should be trained on the chosen triage system. For those with no prior triage experience for this setting, exercises should take place. Some experts recommend that the triage method be published in team member guide- lines and that there be an early practice session for all team members on the opening day of the event. Another suggestion is that posters explaining the triage system be developed and distributed to medical facilities (including receiving hospitals), casualty clearing stations, and each first aid post.

Required Resources

Management of a mass gathering from the medical perspective requires human resources, medical equipment, pharmaceuticals, and medical facilities with sufficient examination rooms on site. For very large events a dedicated logistician would be useful. In 2000, Jaslow, on behalf of the NAEMSP, produced a docu- ment entitled Mass Gathering Medical Care: The Medical Direc- tors Checklist.77 This is a comprehensive resource for anyone involved in directing medical care at mass gatherings. It contains great detail regarding medical equipment needs, including essen- tial and desirable components for basic and advanced medical interventions.

Estimating Medical Resources

Don’t live in a town where there are no doctors. Jewish Proverb

There are no international standards for the numbers of physi- cians, training requirements, or level of care that should be pro- vided at mass gatherings. Although not necessarily evidence- based, event licensing regulations or local statutes and ordinances may specify required numbers of medical personnel. If they exist, such ordinances or statutes specify minimum levels of physi- cian coverage and have usually not been updated to account for increased duties and medical developments locally, nationally, or internationally. Estimating medical resources required for any mass gathering is an inexact science and may involve real-time adjustments to ensure that sufficient resources are present on site. For the first iteration of an event, it is better to overestimate

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staffing and equipment requirements than to risk the conse- quences of understaffing or underresourcing. Once experience is gained from the same or similar events on multiple occa- sions, patterns will emerge that allow for a more valid estimate of the true requirements for human resources, equipment, and transportation assets. Even when good data are available, it is prudent to provide more than just the minimum numbers of staff and a system for surge capacity in case of a sudden increase in health and medical demands.

Organized planning for mass gatherings at stadia is relatively new, beginning over the last two decades. Retrospective analysis of attendance rates on site for medical treatment, medication and equipment use, transport to hospitals, and audit of medical records provides planning guidance for minimum requirements for an event of similar size in the same jurisdiction. Although generic planning elements are similar, no two mass gatherings have identical requirements even when planned for the same site, crowd number, and activities. Resources requirements are dependent on a variety of factors including

■ Jurisdiction and legal safety standards ■ Level of care in local EMS system ■ Distance to definitive medical care ■ Time period before outside assistance arrives (i.e., how long

stadium needs to be self-sufficient)

The total medical resources required to manage medical services at a mass gathering include but are not limited to

■ Ambulance personnel and on-site ambulance officer ■ Communications officer(s) ■ EMS director ■ Paramedics ■ First aid workers/Volunteers/First responders ■ Nurses ■ Physicians, including medical director and deputy director(s) ■ Ambulance service managers ■ Support units ■ Ambulances ■ On-site transport vehicles ■ Event safety officer/Event controller (provided by event orga-

nizer)

Since health systems vary widely there is no universal matrix to calculate staff numbers, grades, or types of services required to provide medical coverage at a mass gathering. In some countries voluntary first aid organizations such as the Red Cross, the St. Johns Ambulance, or the Order of Malta may provide medical services without an on-site physician. In other regions local refer- ral hospitals operate temporary facilities on site in an attempt to prevent unmanageable patient volumes from being transported to their existing fixed facilities.

The U.K. Health Services Executive in conjunction with the Home Office and Scottish Office published The Guide to Health, Safety and Welfare at Pop Concerts and Other Similar Events in 1993. This was updated in 1999 to reflect changes in U.K. health and safety law and to update best practices. The Event Safety Guide was developed in consultation with an event industry working group and is the standard for managing health and safety at such events.74 Although it has no legal basis in Ireland, it is regularly referenced in planning meetings in conjunction with the Codes of Practice for Safety at Sports Grounds, Safety

Table 17.2: Event Nature

Score

(A) Nature of Event Classical performance 2

Public exhibition 3

Pop/rock concert 5

Dance event 8

Agricultural/country show 2

Marine event 3

Motorcycle display 3

Aviation 3

Motor sport 4

State occasions 2

VIP visits/summit 3

Music festival 3

Bonfire/pyrotechnic display 4

New Year’s celebrations 7

Demonstrations/marches/ political events low-risk disorder

Medium-risk disorder 5

High-risk disorder 7

Opposing factions involved 9

(B) Venue Indoor 1

Stadium 2

Outdoor, confined location, e.g., park

Other outdoor, e.g., festival 3

Widespread public locations in streets

Temporary outdoor structures 4

Includes camping 5

Mixed 2

Standing 3

(D) Audience Profile Full mix in family groups 2

Full mix, not in family groups 3

Predominantly young adults 3

Predominantly children, teenagers

Predominantly elderly 4

Full mix, rival factions 5

Add (A) + (B) + (C) + (D) Total Score for table 1

Source: From the Event Safety Guide, published by Her Majesty’s Stationery Office.

at Outdoor Pop Concerts and Safety at Indoor Concerts, which are government-sponsored documents.85–87 These are examples of country specific documents that outline basic levels of care

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Table 17.3: Event Intelligence, Event Safety Guide

Score

(E) History Good data low casualty rate previously (less than 1%)

−1

Good data medium casualty rate previously (1%–2%)

Good data high casualty rate previously (more than 2%)

First event, no data 3

(F) Expected Numbers <1,000 1

<3,000 2

<5,000 8

<10,000 12

<20,000 16

<30,000 20

<40,000 24

<60,000 28

<80,000 34

<100,000 42

<200,000 50

<300,000 58

Add (E) + (F) Total Score for table 2 –

Source: From the Event Safety Guide, published by Her Majesty’s Stationery Office.

and resources that attendees can expect to receive at music and sports events.

The Event Safety Guide contains tables that are helpful for estimating a reasonable level of resources that should be provided at events. These guidelines provide a good framework; however, they were developed based on the levels of care available in a particular jurisdiction and may not be applicable in all coun- tries. Data from Tables 17.2–17.4 can be combined to provide a scoring system that can be applied to Table 17.5 to calculate recommended resource requirements.

Equipment

A useful approach in determining the equipment needed for a mass gathering is to coordinate with the local ambulance services. Many ambulance services have disaster/major incident–specific equipment in significant quantities with procedures for rapid restocking when necessary. This equipment can be staged directly on site or in proximity.

Planners should be prepared for unanticipated changes in requirements and develop flexible command and control sys- tems that can accommodate unexpected events. For example, at a mass gathering in Ireland, cloudy weather was predicted. A heat wave occurred unexpectedly on the second day of the event and resulted in large numbers of patients seeking treatment for sunburns. Patrons from out of town and members of the on-site medical team rapidly depleted supplies of sunscreen and “after sun” products from stores and pharmacies within a 32-km radius of the event.88 This illustrates the need to be creative in obtaining unanticipated resources.

Table 17.4: Sample Additional Considerations, Modified from the Event Safety Guide

Score

(G) Expected Queuing <4 h 1

>4 h 2

>12 h 3

(H) Time of Year (Outdoor events) Summer 2

Autumn 1

Winter 2

Spring 1

(I) Proximity to <30 min by road 0

Definitive Care (closest suitable emergency department)

>30 min by road 2

( J) Profile of Definitive Care Choice of EDs 1

Large volume ED 2

Small Volume ED 3

(K) Additional Hazards Carnival 1

Helicopters 1

Motor Sport 1

Parachute Display 1

Street Theater 1

(L) Additional On-site Facilities Suturing 2

X-ray 2

Minor surgery 2

Plastering 2

Psychiatric/Primary care facilities

Add (G) + (H) + (I) + (J) + (K) + (L) Total Score for table 3 –

Source: Modified from the Event Safety Guide, published by Her Majesty’s Stationery Office.

It is difficult to estimate the exact quantity of pharmaceuti- cals that will be required. Planners should develop a restocking agreement with a local pharmacy or the local health service. Some medications require refrigeration. Controlled substances will need to be appropriately secured. One approach would be to designate one of the medical teams as being responsible for sign out of controlled drugs with signature policies on a named patient basis.

Additional field hospital supplies and resources include

■ Beds/cots/trolleys ■ Tables and chairs ■ Sinks ■ Access to electrical power ■ Sheets ■ Blankets ■ Pillows ■ Towels ■ Drapes ■ Patient identification bracelets ■ Refrigerators ■ Safety pins

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Table 17.5: Suggested Resource Requirements, from the Event Safety Guide

National Health First Aid Ambulance Service Ambulance Support

Score Ambulance Worker Personnel Doctor Nurse Manager Unit

<20 0 4 0 0 0 0 0 21–25 1 6 2 0 0 visit 0 26–30 1 8 2 0 0 visit 0 31–35 2 12 8 1 2 1 0 36–40 3 20 10 2 4 1 0 41–50 4 40 12 3 6 2 1 51–60 4 60 12 4 8 2 1 61–65 5 80 14 5 10 3 1 66–70 6 100 16 6 12 4 2 71–75 10 150 24 9 18 6 3 >75 15+ 200+ 35+ 12+ 24+ 8+ 3

Source: From the Event Safety Guide, published by Her Majesty’s Stationery Office.

■ Pen and paper ■ Patient report forms ■ Nonhazardous waste bins ■ Hazardous waste bins ■ Head lamps ■ Floor lamps ■ Phones ■ Fax machines ■ Printers ■ Laptop computers ■ Lock boxes for pharmaceuticals ■ Spare batteries (multiple sizes) ■ Flashlights: large and small for examination ■ Access to bathroom

Medical equipment includes

■ 12-lead EKG machine, paper stock, skin razors ■ Airway equipment (Ambu bags, laryngoscopes, blades/

batteries/airways endotracheal and nasal/oropharyngeal and laryngeal masks, Airtraq devices, saturation probes, portable pulse oximeters, portable face masks, oxygen masks)

■ Automated blood pressure monitors ■ Bandages/gauze pads/band aids and elastoplast/adhesive

tapes ■ Betadine ■ Blankets ■ Blood glucose strips, monitors, ketone measuring strips ■ Broselow tapes (to estimate pediatric weights and drug doses) ■ Burn dressings ■ Cotton balls ■ Defibrillator – AED (Numbers dependent on-site layout) ■ Delivery packs for obstetrics ■ End-tidal CO2 monitors ■ EZ IO intraosseous access devices ■ Face masks

Gloves: sterile/nonsterile, latex/nonlatex, multiple sizes

■ Intravenous fluid infusers ■ Intravenous fluids ■ Intravenous devices and tubing ■ Multiple cervical collars – adult and pediatric (or universal)

sizes

■ Nasogastric tubes ■ Needle cricothyroidotomy kits and supplies ■ Needle thoracostomy kit/portable chest tube kit ■ Neonatal resuscitators ■ Thermometers ■ Observation monitors ■ Ophthalmoscopes ■ Otoscopes ■ Oxygen tanks, regulators, masks, and nasal cannulae ■ Portable ventilators ■ Prescription pads ■ Ring cutters ■ Skin closure devices (steri strips, tissue adhesive, skin clips,

suture kits, and sutures) ■ Snellen charts ■ Spinal boards ■ Splints: multiple sizes/slings/dynacast/crutches ■ Stethoscopes (electronic with volume control at rock con-

certs) ■ Suction devices (with chargers), suction catheters ■ Trauma scissors ■ Urinalysis strips ■ Vaseline gauze and tubs

Pharmaceuticals Drugs can be categorized according to the ABCDEs of mass

gatherings as described previously. Even with this comprehensive approach, it is likely that medical needs will occasionally exceed immediate resources. For this reason, planners should develop policies for medication restocking, for example, with local phar- macists. The following represents the classes of drugs that should be available on site. Airway

■ Bronchodilators ■ Induction agents ■ Nebulized and oral steroids ■ Paralytic agents

Allergic reactions/Anaphylaxis

■ Epinephrine ■ Oral and topical steroids ■ Oral and topical antihistamines

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Analgesics

■ Aspirin (also for chest pain) ■ Acetaminophen ■ Antacids (proton pump inhibitors, H2 blockers) ■ Antiinflammatory medications ■ Nonsteroidal antiinflammatory agents ■ Opioid analgesics ■ Other nonnarcotic analgesics

Breathing

■ Antibiotics ■ Bronchodilators

Bites/Burns/Bones/Back pain

■ Point of care tests for tetanus immunity (desirable because there is growing evidence that most persons in industrialized societies are immune even though they may think they are not)89,90

■ Vaccines: Antitetanus/Hepatitis B passive and active immu- nization (particularly for “fight bites”)

■ Water gel/Silver sulfadiazine cream or similar ■ Analgesics as above ■ Local anesthetics

Circulatory problems: ACLS medications

■ Adenosine ■ Amiodarone ■ Atropine ■ Beta blockers ■ Calcium chloride ■ Calcium channel antagonists ■ Digoxin ■ Epinephrine ■ Lidocaine ■ Nitroglycerin ■ Vasopressor agents ■ Sodium bicarbonate ■ Thrombolytic agents (consider if delay to definitive care)

Disability assessment: stroke, headaches

■ Analgesics ■ Antibiotics (if suspect meningitis and delay to lumbar punc-

ture/definitive care)

Drug ingestion/Drug exposure/Drug overdose/Diabetic emer- gencies/Drowning

■ Activated charcoal (efficacy questionable) ■ Antidotes to common poisons ■ Antiepileptic medications (lorazepam/

diazepam/midazolam) ■ Antihistamines (topical, oral, and parenteral) ■ Dantrolene (for MDMA poisoning with hyperpyrexia) ■ 50% dextrose ■ Glucagon ■ Induction agents ■ Insulin ■ Steroids (oral and parenteral)

Electrocution/Environmental emergencies/Eye and ENT presen- tations

■ Topical anesthetics ■ Topical antibiotics (ophthalmological preparations) ■ Topical antibiotics (aural preparations) ■ Irrigating solutions ■ Mydriatic agents ■ Fluorescein dye (strips or drops) ■ pH strips

Soft tissue injuries/Skin problems/Psychiatric emergencies/ Syncope/Seizures/Spinal assessments in trauma

■ Antiepileptics (lorazepam/diazepam/midazolam, including rectal diazepam)

■ Anxiolytics ■ Skin closure aids (steri strips/tissue adhesive/staples, and

sutures) ■ Topical antihistamines/steroids/antibiotics/antifungals ■ Oral and systemic antibiotics ■ Sedatives ■ Local anesthetics

Other Antidiarrheal agents

Transport (On and Off Site)

Transportation vehicles can include golf carts for football sta- diums and quadcycles for rougher terrain, particularly when there are large distances over open spaces with a potential for boggy ground with precipitation. In Ireland, St. Johns Ambu- lance Brigade volunteers use specially designed mountain bikes as personal means of transportation to move around the site.

Mass gatherings can encompass large areas and difficult envi- ronments. For example, in the annual Glastonbury festival, the distance from one of the campsites to the main arena is large and could include muddy areas. Without proper vehicles it would be nearly impossible to move patients under such conditions. Standard heavy ambulances will not easily traverse this terrain. Alternate vehicles such as quadcycles or SUV-type ambulances would be needed, especially in very muddy conditions. If not anticipated well ahead of the event, it may be difficult to secure environment appropriate vehicles. Staffing levels should be suf- ficient to ensure timely responses to critical areas in venues span- ning large geographical areas or events with multiple stadia.

The local ambulance service typically organizes transport from the event site to local emergency departments. They may be delays in ambulances returning to the venue, for example, if there are prolonged handovers at the local ED or ambulances are needed for secondary transfer of patients from the closest hospital to a higher level of care. Staffing and transportation resources must account for such situations, particularly if an event physician is accompanying a patient off site or during an interfacility transfer.

Medical Indemnity – Medical Malpractice Physicians providing medical coverage at mass gathering

events need to be sure they are protected from liability. Although event promoters generally have public liability, weather, and “no- show” insurances, they are unlikely to provide medical liability

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coverage. The system of medical malpractice or medical indem- nity as it is termed in Europe is generally based on an indi- vidual practitioner’s specialty and routine medical practice and not occasional work such as that performed at a mass gathering event.

There is a significant difference between the two terms and it is important that physicians know which variant they possess. Malpractice insurance or liability coverage as it is called in the United States means the physician has an insurance product that covers the financial cost of a malpractice incident or the cost of defending a negligence claim. To obtain such coverage individual physicians detail their work plans including specific information on their involvement in medical activities outside their primary specialty (such as mass gathering medical care). This is then factored in to the cost of the liability coverage. If an event has not been prospectively included in the work plan, the physician must make a separate request to the liability insurer for coverage.

Medical indemnity on the other hand is not an insurance- based product. Physicians become members of mutual medical societies such as the Medical Defense Union and the Medical Protection Society. The organizations were founded in the 19th century as nonprofit bodies that assist members with legal and ethical problems arising from clinical practice. The benefits of membership are discretionary. Although rare, these organiza- tions may elect not to assist with the financial consequences of a claim against a member.

Mass gathering medical care is a new concept and liability insurers and indemnification bodies have little experience with it. Therefore when obtaining liability coverage, it is advisable to carefully define physician roles and responsibilities (including how this might change after a major incident or disaster).

In Ireland one of the bodies involved, Medisec, which now has an insurance policy for its members, specifically states that for general practitioners (family physicians)

The policy will not indemnify GP’s in respect of any liability arising from or directly or indirectly caused by advice and/or treatment not coming within the range of services normally provided by a general practitioner.

The policy specifically excludes acting as an event doctor (med- ical director) who is responsible for crowd control, ambulance services, provision of appropriate medical equipment, and other related activities. This significantly limits the number of doctors in Ireland who are willing to operate in such roles.

Few if any physicians work full time in mass gathering med- ical care. More typically, this activity reflects a small portion of a physician’s overall medical practice. Thus there is limited case law available to insurers for decision making. In addition, a physician who provides medical services at an event needs different types of liability coverage than a physician in the role of event medi- cal director who is involved in planning and organizing medical care. The level of responsibility for a medical director or Medical Incident Officer in case of a disaster is much greater than for a physician providing direct medical care at the event.

In the United Kingdom and Ireland, large medical indemnity bodies such as The Medical Union and The Medical Protection Society do not generally permit physicians to function at such events in roles not part of their normal practice, e.g., physicians without regular trauma experience who assess patients injured at events, or physicians without toxicology training and experience who manage overdose patients at a mass gathering. In instances in

which physicians must perform services outside of their normal scope of practice, it might be advisable to maintain certification in relevant courses such as ATLS, ACLS, MIMMS, or pediatric trauma management.

Medical Protection Society: 10 Best Practice Points for Doc- tors Providing Services at Sports Events

1) Ensure your skills are up to date and that qualifications are appropriate to those required for a specific event.

2) Acquire sufficient knowledge of the sport being played. You should be aware of the risks involved and the likely nature and severity of possible injuries.

3) Be prepared for all medical emergencies, including those that are not sports related.

4) Ensure that you have access to the appropriate medical equip- ment and resources that your risk assessment has identified as being required.

5) Know and follow the guidance published by the sport’s gov- erning body.

6) Be familiar with the local emergency services and ensure you are aware of and comfortable with the level of support available.

7) Arrange appropriate professional indemnity. 8) Ensure that the extent of your responsibilities is defined and

agreed with the event organizer in advance. Specifically, are you responsible for spectators and event staff as well as the participants?

9) You may wish to speak to the referee/umpire regarding arrangements for stopping play if necessary.

10) If you are dissatisfied with the support facilities and resources available, you should bring this to the attention of the event organizer and consider objecting to the event proceeding until the situation has been rectified.

Medical Records

Maintaining medical records is important but can be challeng- ing because mass gatherings are infrequent events. Voluntary bodies such as the Red Cross, the St. John Ambulance Brigade, and the Order of Malta have decades of experience providing medical care at mass gatherings and have produced their own standardized medical records. In general these are single sided A4 pages, occasionally triplicate forms containing basic demo- graphics, nature of the incident, and nature of the treatment given with a record of whether the patient was discharged, referred for more senior opinion, seen by a physician, or transported to a hospital. Although additional detail is desirable for a mass gath- ering event medical record, on a practical level, documentation will not be as detailed or comprehensive as a hospital chart. At the time of this writing most events use paper records because electronic medical records and Wi-Fi transmission of data on site are not yet fiscally viable options. Records should be kept for 30 years or longer, consistent with local guidelines and regulations.

Four forms of documentation are required: 1) patient med- ical record (PMR), 2) injured staff medical record (ISMR), 3) patient transfer record (PTR), and 4) running tally of patients treated and transported and the resources used.

Patient Medical Record The essential data set should include

■ Day of week ■ Date

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■ Venue ■ Event name ■ Medical post location ■ Transfer on site – post transferred to ■ Transfer off site – destination, hospital name ■ Location of incident (if injury) ■ Time of incident (if injury) ■ Level of healthcare provider (First Aid, EMT, Paramedic,

Nurse, Physician) ■ Name of healthcare provider ■ Name of patient ■ Date of birth of patient ■ Cell phone number of patient ■ Details of transport to venue (arrangements may need to be

made for transfer home posthospital treatment) ■ Details of illness or injury ■ Medical history (if relevant) ■ Current medications (if relevant) ■ Incident related to alcohol ingestion ■ Incident related to illicit drug ingestion, name of drug, quan-

tity taken, description of drug (color/shape/symbols) ■ Observations (vital signs, pupil size and response, oxygen

saturation, 12-lead EKG, if applicable) ■ Physical examination ■ Differential diagnosis ■ Treatments given, including

■ Airway management required? (yes/no) (type) ■ Intravenous line required? (yes/no) ■ Fluids administered intravenously? (yes/no) ■ Medication names and doses ■ Splint required? (yes/no)

A triplicate form is used by some event planners. The treating physician receives a copy at the end of the event to maintain a record of patients treated. A second copy is given to the voluntary agency involved in treatment if any. The third copy is maintained by the event medical director as an overall record of the patients treated. This allows for record maintenance and audit of medical service requirements to assist in postevent report writing. In the absence of triplicate forms a photocopier should be part of the equipment brought to the event.

In some jurisdictions event promoters provide branded notepaper for use as medical records and argue that because they own the paper they also own the record. They claim they need records to protect against potential future litigation. Although medical record keeping is important for clinicians providing direct medical care, it would be better to provide anonymous summary statistics for the event promoter. If actual records are later required for litigation, the medical director can produce the original. Local medical licensing authorities can assist with ensur- ing systems are in place to protect confidential patient health information.

Injured Staff Medical Record In addition to the aforestated elements, the ISMR should

include the following

■ Nature of the injury ■ Was personal protective equipment being used? (yes/no) ■ If not, why not? ■ Staff title and role ■ Able to resume work? (yes/no)

A separate file should be kept on injured staff particularly if there is mandatory reporting of workplace accidents.

Patient Transfer Record In addition to the information on the basic PMR, the PTR

should include

■ Reason for transfer ■ Details of accompanying persons/cell phone numbers ■ Physicians name and contact details

Treatment Facilities

During the planning phase, the medical director, in conjunction with the ambulance service, should determine the number, loca- tion, and size of medical facilities including first aid stations to be provided on site. If there is more than one medical facility, the director should designate a field hospital or medical center. A facility should also be designated as a casualty clearing station for field triage in the event of a major incident.

Satellite medical facilities should be highly visible and eas- ily identifiable from a distance to roaming medical staff. The satellite medical facilities and first aid posts should be located on the peripheries of the audiences in the main arenas to enable unrestricted access and egress for ambulances. Maps should be available for all medical and first aid staff to ensure that they know response locations after receiving a radio call. Generally there will be a medical facility at one or both sides of the main stage as this is where the largest crowd concentration will be. Historically the greatest numbers of crowd crushing injuries have occurred at the areas of highest patron density.

At large sites consideration should be given to having mobile response teams with the skill mix to be able to provide initial resuscitation to unconscious patients with unprotected airways. Teams should operate in pairs.

Medical facilities should not permit smoking; however, in the absence of legislation this may be difficult to impose. If oxygen is used in the main medical facility, patrons must be restrained if they are trying to gain entry while smoking. The number of treat- ment gurneys will depend on the estimated crowd size but a min- imum of six ambulance stretchers or examination tables should be provided. Local ordinances may specify exact sizes, materials to be used in construction, and utilities to be provided. For exam- ple, in Ireland the minimum size for a main medical facility is 25 m2 for crowds in excess of 15,000 and 15 m2 for smaller crowds. Facilities must contain hot and cold running water, a telephone with outside line capability, heating, lighting, ventilation, electri- cal sockets, and examination couches. They should be staffed by nurses and doctors experienced in emergency work, and first aid workers to assist with patient observation. Emergency vehicles must have ready access. Toilets restricted from general public use must be available proximate to the medical facility.

Doorways should be large enough for wheelchair access. Although equipment lists are not specified, it would be stan- dard to provide defibrillators both in the facility and situated around the venue, usually automated or semiautomated exter- nal defibrillators (AEDs). Several experts have suggested math- ematical formulae to assist in determining the number of AEDs needed at mass gathering sites. Crucco derived a formula based on stadium area, severity of slopes, stairway distances, and hori- zontal distances to achieve certain targeted response times.91 At the University of North Carolina, Motyka completed a similar

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study in the football stadium (capacity 60,000) and the basket- ball stadium (capacity 21,444).92 Multivenue events with pass access restrictions and variable crowd densities along the routes present additional challenges. In these situations, roving teams with portable defibrillators in addition to fixed-site AEDs can decrease time to defibrillation.

Communications

Communications requirements will depend on the event setting and the number of people present. If not already available in the stadium, the event promoter usually provides communications systems. For events situated in remote areas, wireless phone ser- vices for voice communications are unreliable because the local cell will likely be overloaded by the volume of cell phones for the duration of the event. There are systems such as Access Overload Control, when in the event of an emergency, the authorities can request the cell in a particular area be shut to all voice traffic except for those on pre-event registered handsets for emergency services. This can be very expensive as the authority has to com- pensate the communications provider for lost revenue, which is calculated from the average traffic in that cell over a reference period. This may be inexpensive in remote areas with low usage volumes on nonevent days. Text messaging is another possibility. Even with limited bandwidth or weak signals there are protected channels for text communications. This system would ensure that there is an audit trail of communications; however, timely message delivery cannot be guaranteed in an overloaded cell.

The choice of communications technology should be made in conjunction with local authorities (police, fire, medical and health) and should conform to community codes of practice for such systems. There should be a central control area on site for the relevant service commanders where they can regularly update each other on developments. This area should have a good view of the event site, if necessary by using closed circuit television. There should be a capability to communicate on two- way multichannel radio sets to event controllers, security, pro- moters, medical and ambulance services, first aid workers, wel- fare personnel, and law enforcement. Two-way communications are preferred from the medical perspective because with one-way communication other users on the same channel cannot hear a colleague’s appeal for help; they will only hear the control room response.

Even with very high quality equipment, it can be difficult to hear radio communications within the main arena or close to a noisy stage. Limited communication may be possible by using brief hand signals or alternatively runners may be used to bring messages directly from place to place with requests for supplies or assistance.

Audit

In the aftermath of the event it is important to perform an audit of the on-site medical care to facilitate quality improvement. Spe- cific areas to address include quality issues, whether appropriate skill mix levels existed on site, levels of care, patient demograph- ics, presentations related to alcohol and drugs, and the effects on off-site health service resources. Analysis of these factors will assist with planning for future similar events to include provid- ing data on appropriate staffing levels required to safely manage a mass gathering.

The following represent important data elements that the medical director should collect to facilitate continuous quality improvement.

■ Number of patients treated and demographics ■ Number of patients treated per post ■ Number of patients who received care from the appropriate

provider ■ Number of patients who were referred to see a more experi-

enced or specialty practitioner ■ Number of transfers off site to other medical facilities and

reasons for transfer ■ Average return to site times for team members accompanying

patients off site ■ Number of hospital admissions and reasons for admission ■ Number of drug-related presentations and drugs involved ■ Numbers of alcohol-related presentations ■ Number of assaults ■ Number of patients treated per hour ■ Time first patient seen ■ Time last patient seen ■ Number of staff seen as patients ■ Numbers and types of injuries occurring in staff ■ Top 10 medical presentation list ■ Medications used and doses ■ Medical equipment used ■ Time to defibrillation

RECOMMENDATIONS FOR FURTHER RESEARCH

The science of mass gathering medicine is in its infancy. Much of the early academic focus has been on descriptive research includ- ing reports of medical involvement at single events.6,30,46,62,93–97

Publication of the NAEMSP’s Medical Director’s Checklist pro- vided a valuable resource beyond the previously published descriptive studies.77

Several authors have emphasized the importance of drills, exercises, advanced preparation, and education; however, more work is needed on how to improve patient outcomes via training and preparedness of all levels of team members.4,98–105 A critical review of the efficacy of current physician training for mass gathering medical care would be valuable.

In recent years a number of reviews of mass gathering litera- ture have been published, most notably by Michael and Milsten. Zeitz published a model predicting the workload at a mass gath- ering.73 Michael in a 25-year review published in Prehospital and Disaster Medicine suggests that a uniform classification scheme is necessary for future prospective studies of mass gatherings.106

Milsten produced a comprehensive literature review examining the variables that can affect patient presentations at events.81 He found that weather, environmental factors, event type and dura- tion, crowd mood, attendance, and crowd density, age, alcohol, and drug use were prominent factors.

In 2007, Arbon published a comprehensive review of the evidence and future directions for research.107 He identifies that there is no consensus definition for mass gathering and suggests using a description that includes nontraditional mass gather- ings such as mass transit systems, shopping complexes, airports, and cruise ships. He delineates accepted principal goals of mass gathering medical care, specifically

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Figure 17.7A. Aerial view of Oxegen music festival 2007 showing main arena, large tents for other concurrent stage performances with multiple campsites in midground and background for up to 70,000 people.

1) Establishing rapid access to ill or injured patients and pro- viding triage

2) Effective and timely stabilization and transportation of seri- ously injured or acutely ill patients

3) Providing on-site care for minor injuries and illnesses

Arbon argues that there is a lack of uniform standards for the provision of health services at mass gatherings with a foundation based on relatively low levels of evidence. This overreliance on “expert level of evidence” leads to marked variations in stan- dards and legislation. Expert level of evidence is an example

of “eminence-based” as opposed to “evidence-based” medicine. Procedures recommended by the eminent “Professor” are fol- lowed as no one would dare question the “expert.” Arbon recog- nizes the need for consensus among the “eminence” in creating commonality of language with respect to data collection. Exam- ples include the use of patients presenting per ten thousand atten- dees (PPTT), transfer to hospital rate (TTHR), patient presenta- tion rate (PPR), and MUR. Until there is an agreed standardized dataset that is collected at mass gathering events there will be no consistency in data collection and it will be impossible to compare similar events (Figure 17.7A and 17.7B).

Figure 17.7B. Aerial view of Electric Picnic Festival showing densely packed camping within a well bordered/sheltered site with multiple performance arenas for simultaneous performances.

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In summary, there is an immediate need for new research that focuses on

■ Appropriate timelines for event planning ■ Liability issues ■ Education and training of medical personnel without prior

mass gathering medicine experience ■ Differences in medical attendance rates for similar events ■ Appropriate levels of care to be delivered at mass gatherings

and benefits of on-site versus off-site treatment ■ Alternatives to hospital transports for diagnostic access ■ Standardized data sets ■ Standardized definitions for events, interventions, and

records ■ Best practice documentation strategies ■ Utilization of Wi-Fi tools and other electronic means for

documentation ■ GPS/RFID tagging for large unbounded events (e.g., to locate

roaming teams with critical patients) ■ Mitigation strategies ■ Outcomes of care provided at mass gatherings ■ Appropriate staffing requirements for medical, nursing, and

other paramedical personnel ■ Reduction of effects on local health services ■ VIP care strategies ■ Impact of licensing legislation in different jurisdictions on

medical attendances

As mass gatherings become more frequent, more experts need to be trained and more research performed to ensure continued reductions in morbidity and mortality among those attending or managing such events.

The world is a dangerous place, not because of those who do evil, but because of those who look on and do nothing.

Albert Einstein

A goal without a plan is just a wish. Antoine de Saint-Exupery

REFERENCES

1. Levett J. A new opportunity for public health development: Athens 2004. Prehosp Disaster Med. 2004;19(2):130–132.

2. The role of the emergency physician in mass casualty/disaster management. ACEP position paper. JACEP. 1976;5(11):901– 902.

3. Manifesto for Emergency Medicine in Europe. Council of the European Society for Emergency Medicine. Eur J Emerg Med. 1998;5(4):389–390.

4. Hsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein C, Cosgrove SE, et al. Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature review. Pre- hosp Disaster Med. 2004;19(3):191–199.

5. Mcdonald R. Career Focus – Event medicine. BMJ Classified. 2001 15th December;323(7324).

6. Kerr GW, Wilkie SC, McGuffie CA. Medical cover at Scottish football matches: have the recommendations of the Gibson Report been met? Br J Sports Med. 1999;33(4):274–275.

7. Avery JG, Chitnis JG, Daly PJ, Pollock GT. Medical planning for a major event: the Pope’s visit to Coventry Airport, 30 May 1982. Br Med J (Clin Res Ed). 1982;285(6334):51–53.

8. Federman JH, Giordano LM. How to cope with a visit from the Pope. Prehosp Disaster Med. 1997;12(2):86–91.

9. El Bashir H, Rashid H, Memish ZA, Shafi S. Meningococcal vaccine coverage in Hajj pilgrims. Lancet. 2007;369(9570):1343.

10. Morrison DJ. Heatstroke on the Hajj. Lancet. 1980;1(8174):935. 11. Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj.

Lancet. 2006;367(9515):1008–1015. 12. Schulte D, Meade DM. The papal chase. The Pope’s visit: a

“mass” gathering. Emerg Med Serv. 1993;22(11):46–9, 65–75, 9. 13. Madani TA, Ghabrah TM, Al-Hedaithy MA, et al. Causes of

hospitalization of pilgrims in the Hajj season of the Islamic year 1423 (2003). Ann Saudi Med. 2006;26(5):346–351.

14. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Pattern of admission to hospitals during Muslim pilgrimage (Hajj). Saudi Med J. 2003;24(10):1073–1076.

15. County Board of Commissioners, Union County, North Car- olina. Ordinance Pertaining to Mass Gatherings. 1974:224–7 Docket 12.

16. An Ordinance for the Regulation of Mass Gatherings in Alleghany County. Alleghany County, North Carolina, 1975.

17. Arkansas State Board of Health. Mass Gathering regulations. 1973.

18. Arnold JL, Levine BN, Manmatha R, et al. Information- sharing in out-of-hospital disaster response: the future role of information technology. Prehosp Disaster Med. 2004;19(3): 201–207.

19. Arbon P, Bridgewater FH, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. Prehosp Disaster Med. 2001;16(3):150–158.

20. Jaslow D, Drake M, Lewis J. Characteristics of state legislation governing medical care at mass gatherings. Prehosp Emerg Care. 1999;3(4):316–320.

21. Best JP, McIntosh AS, Savage TN. Rugby World Cup 2003 injury surveillance project. Br J Sports Med. 2005;39(11):812–817.

22. Cheng D, Yakobi-shvili R, Fernandez J. Major sport cham- pionship influence on ED sex census. Am J Emerg Med. 2005;23(3):408–409.

23. Roberts DM, Blackwell TH, Marx JA. Emergency medical care for spectators attending National Football League games. Pre- hosp Emerg Care. 1997;1(3):149–155.

24. Moreno Millan E, Bonilla F, Alonso JM, Casado F. Medical care at the VIIth International Amateur Athletics Federation World Championships in Athletics ‘Sevilla ’99’. Eur J Emerg Med. 2004;11(1):39–43.

25. Bock HC, Cordell WH, Hawk AC, Bowdish GE. Demographics of emergency medical care at the Indianapolis 500 mile race (1983–1990). Ann Emerg Med. 1992;21(10):1204–1207.

26. Ma OJ, Millward L, Schwab RA. EMS medical coverage at PGA tour events. Prehosp Emerg Care. 2002;6(1):11–14.

27. Morimura N, Katsumi A, Koido Y, et al. Analysis of patient load data from the 2002 FIFA World Cup Korea/Japan. Prehosp Disaster Med. 2004;19(3):278–284.

28. The price of pop. Lancet. 1971;2(7726):696–697. 29. Carveth SW. Eight-year experience with a stadium-based mobile

coronary-care unit. Heart Lung. 1974;3(5):770–774. 30. Fisher JM. The British Association for Immediate Care

(BASICS). Its experience in major disasters, with special ref- erence to the role of the medical incident officer. Injury. 1990; 21(1):45–48; discussion 55–57.

31. Slater D. Hillsborough television drama. Br Med J. 1997; 314(7084):901–902.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

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ve rs

ity P

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. A ll

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s re

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ed .

MA NAG E M E N T O F MA S S GAT H E R I N G S ■ 251

32. Wardrope J, Hockey MS, Crosby AC. The hospital response to the Hillsborough tragedy. Injury. 1990;21(1):53–4; discussion 5–7.

33. Heller T. Personal and medical memories from Hillsborough. Br Med J. 1989;299(6715):1596–1598.

34. Walker E. Not all those who died after Hillsborough did so by 3:15 pm. Br Med J. 1997;314(7089):1283.

35. DeAngeles D, Schurr M, Birnbaum M, Harms B. Traumatic asphyxia following stadium crowd surge: stadium factors affect- ing outcome. WMJ. 1998;97(9):42–45.

36. Khoosal DI, Broad JA, Smith RJ, Settle JA. A one-year psycho- logical follow-up of the most severely burned victims of the Bradford fire. Burns Incl Therm Inj. 1987;13(5):411–415.

37. Sivaloganathan S, Green MA. The Bradford fire disaster. Part 2. accident reconstruction: who died, when and why. Med Sci Law. 1989;29(4):284–286.

38. Sivaloganathan S, Green MA. The Bradford fire disaster. Part 1. The initial investigations: who died, where and how? Med Sci Law. 1989;29(4):279–283.

39. Ayton FD, Hill CM, Parfitt HN. The dental role in the identifi- cation of the victims of the Bradford City football ground fire. Br Dent J. 1985;159(8):262–264.

40. Sharpe DT, Roberts AH, Barclay TL, et al. Treatment of burns casualties after fire at Bradford City football ground. Br Med J (Clin Res Ed). 1985;291(6500):945–948.

41. Sharpe DT, Foo IT. Management of burns in major disasters. Injury. 1990;21(1):41–4; discussion 55–57.

42. Leonard RB. Medical support for mass gatherings. Emerg Med Clin North Am. 1996;14(2):383–397.

43. Brock SH, Schlicht J. Medical aspects of large outdoor festivals. Lancet. 1972;1(7761):1178.

44. Schlicht J, Mitcheson M, Henry M. Medical aspects of large outdoor festivals. Lancet. 1972;1(7757):948–952.

45. Erickson TB, Aks SE, Koenigsberg M, Bunney EB, Schurgin B, Levy P. Drug use patterns at major rock concert events. Ann Emerg Med. 1996;28(1):22–26.

46. Ounanian LL, Salinas C, Shear CL, Rodney WM. Medical care at the 1982 US Festival. Ann Emerg Med. 1986;15(5):520–527.

47. Nix CM, Khan IJ, Hoban M, Little G, Keye G, O’Connor HJ. Oxegen 2004: the impact of a major music festival on the work- load of a local hospital. Ir Med J. 2006;99(6):167–169.

48. Chapman KR, Carmichael FJ, Goode JE. Medical services for outdoor rock music festivals. Can Med Assoc J. 1982;126(8):935– 938.

49. Tait I. General practitioner and his music festival. Br Med J (Clin Res Ed). 1981;283(6292):647–648.

50. Grange JT, Green SM, Downs W. Concert medicine: spectrum of medical problems encountered at 405 major concerts. Acad Emerg Med. 1999;6(3):202–207.

51. O’Keefe JS, Kheir JN, Martin ML, Leslie LF, Neal JG, Edlich RF. Balcony collapse at the University of Virginia graduation: what hath Jefferson wrought? J Emerg Med. 199917(2):293–297.

52. Martinez JM. Medical coverage of cycling events. Curr Sports Med Rep. 2006;5(3):125–130.

53. Yan CB, Rubin AL. Equipment and supplies for sports and event medicine. Curr Sports Med Rep. 2005;4(3):131–136.

54. Grange JT. Planning for large events. Curr Sports Med Rep. 2002;1(3):156–161.

55. Mortelmans LJ, Van Rossom P, Du Bois M, Jutten G. Carbon monoxide load in indoor carting. Eur J Emerg Med. 2003;10(2): 105–107.

56. DeLorenzo RA, Gray BC, Bennett PC, Lamparella VJ. Effect of crowd size on patient volume at a large, multipurpose, indoor stadium. J Emerg Med. 1989;7(4):379–384.

57. Larkin M. Medical teams geared up for winter Olympics. Lancet. 2002;359(9304):412.

58. Baker WM, Simone BM, Niemann JT, Daly A. Special event medical care: the 1984 Los Angeles Summer Olympics experi- ence. Ann Emerg Med. 1986;15(2):185–190.

59. Thackway SV, Delpech VC, Jorm LR, McAnulty JM, Visotina M. Monitoring acute diseases during the Sydney 2000 Olympic and Paralympic Games. Med J Aust. 2000;173(6):318–321.

60. Wetterhall SF, Coulombier DM, Herndon JM, Zaza S, Cantwell JD. Medical care delivery at the 1996 Olympic Games. Centers for Disease Control and Prevention Olympics Surveillance Unit. JAMA. 1998;279(18):1463–1468.

61. Morimura N, Takahashi K, Katsumi A, et al. Mass gathering medicine for the First East Asian Football Championship and the 24th European/South American Cup in Japan. Eur J Emerg Med. 2007;14(2):115–117.

62. Madzimbamuto FD. A hospital response to a soccer stadium stampede in Zimbabwe. Emerg Med J. 2003;20(6):556–559.

63. Tang N, Kraus CK, Brill JD, Shahan JB, Ness C, Scheulen JJ. Hospital-based event medical support for the Baltimore marathon, 2002–2005. Prehosp Emerg Care. 2008;12(3):320– 326.

64. Bowdish GE, Cordell WH, Bock HC, Vukov LF. Using regression analysis to predict emergency patient volume at the Indianapolis 500 mile race. Ann Emerg Med. 1992;21(10):1200–1203.

65. Auerbach PS, Gelb AM, Turns JE. Emergency medical services at the 1984 Democratic National Convention. Ann Emerg Med. 1985;14(7):709–711.

66. Avsarogullari L, Ikizceli I, Sozuer E, Yurumez Y, Kilic S. Hand injuries during a Muslim Sacrifice Festival. Am J Emerg Med. 2004;22(6):508–509.

67. The Football Association of Ireland – Club Licensing Manual. Dublin, Ireland: FAI 2004:118.

68. Murphy D, Jabbar N, Eldin M, Gillen P. Audit of the impact of a major pop concert on the workload of two regional hospitals. Ir Med J. 2001;94(1):15.

69. Zeitz KM, Schneider DP, Jarrett D, Zeitz CJ. Mass gathering events: retrospective analysis of patient presentations over seven years. Prehosp Disaster Med. 2002;17(3):147–150.

70. Chambers J, Guly H. The impact of a music festival on local health services. Health Trends. 1991;23(3):122–123.

71. Grange JT, Baumann GW, Vaezazizi R. On-site physicians reduce ambulance transports at mass gatherings. Prehosp Emerg Care. 2003;7(3):322–326.

72. Sanders AB, Criss E, Steckl P, Meislin HW, Raife J, Allen D. An analysis of medical care at mass gatherings. Ann Emerg Med. 1986;15(5):515–519.

73. Zeitz KM, Zeitz CJ, Arbon P. Forecasting medical work at mass- gathering events: predictive model versus retrospective review. Prehosp Disaster Med. 2005;20(3):164–168.

74. Bacon J. The Event Safety Guide. 2nd ed. Sudbury, Suffolk, UK: HSE Books; 1999.

75. Calabro J, Krohmer J, Rivera-Rivera E, Balcombe D, Reich J. Pro- vision of Emergency Medical Care for Crowds. American College of Emergency Physicians; 1996.

76. Jaslow D, Yancy A 2nd, Milsten A. Mass gathering medical care. National Association of EMS Physicians Standards and Clinical Practice Committee. Prehosp Emerg Care. 2000;4(4):359–360.

77. Jaslow D, Yancy A 2nd, Milsten A. Mass Gathering Medical Care: The Medical Director’s Checklist. National Association of EMS Physicians (NAEMSP); 2000.

78. Barbeschi M, Healing T. Communicable disease alert and response for mass gatherings – Key considerations. World Health Organization; June, 2008.

C op

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ht ©

2 00

9. C

am br

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ve rs

ity P

re ss

. A ll

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s re

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ed .

252 ■ MI C H A E L S. MO L LOY, ZA N E SH E R I F, STA N NAT I N, A N D JO H N MCD O N N E L L

79. Ryan JM, Noone E, Plunkett PK. Review of a mobile accident and emergency unit at a rock concert. Ir Med J. 1994;87(5):148–149.

80. Milsten AM, Seaman KG, Liu P, Bissell RA, Maguire BJ. Variables influencing medical usage rates, injury patterns, and levels of care for mass gatherings. Prehosp Disaster Med. 2003;18(4):334– 346.

81. Milsten AM, Maguire BJ, Bissell RA, Seaman KG. Mass- gathering medical care: a review of the literature. Prehosp Disas- ter Med. 2002;17(3):151–162.

82. Black JJ. Emergency use of the Airtraq laryngoscope in traumatic asphyxia: case report. Emerg Med J. 2007;24(7):509–510.

83. Maharaj CH, Ni Chonghaile M, Higgins BD, Harte BH, Laf- fey JG. Tracheal intubation by inexperienced medical residents using the Airtraq and Macintosh laryngoscopes – a manikin study. Am J Emerg Med. 2006;24(7):769–774.

84. Timmermann A, Russo SG, Rosenblatt WH, et al. Intubating laryngeal mask airway for difficult out-of-hospital airway man- agement: a prospective evaluation. Br J Anaesth. 2007;99(2):286– 291.

85. Code of Practice for Safety at Outdoor Pop Concerts and other Musical Events. Department of Education, The Stationery Office, Government of Ireland Publications, 1996.

86. Code of Practice for Safety at Sports Grounds. Department of Education, The Stationery Office, Government of Ireland Pub- lications, 1996.

87. Code of Practice for Safety at Indoor Concerts. Department of Environment and Local Government, The Stationery Office, Government of Ireland Publications, 1998.

88. Mcdonnell JG. Need for adequate sunscreen and after sun prod- ucts at summer events. Personal communication ed. Dublin: email 2002.

89. Stubbe M, Swinnen R, Crusiaux A, Mascart F, Lheureux PE. Seroprotection against tetanus in patients attending an emer- gency department in Belgium and evaluation of a bedside immunotest. Eur J Emerg Med. 2007;14(1):14–24.

90. Stubbe M, Mortelmans LJ, Desruelles D, et al. Improv- ing tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study. Emerg Med J. 2007;24(9):648–653.

91. Crocco TJ, Sayre MR, Liu T, Davis SM, Cannon C, Potluri J. Mathematical determination of external defibrillators needed at mass gatherings. Prehosp Emerg Care. 2004;8(3):292–297.

92. Motyka TM, Winslow JE, Newton K, Brice JH. Method for deter- mining automatic external defibrillator need at mass gatherings. Resuscitation. 2005;65(3):309–314.

93. Britten S, Whiteley MS, Fox PF, Goodwin MI, Horrocks M. Medical treatment at Glastonbury Festival. Br Med J. 1993;307(6910):1009–1010.

94. Delaney JS, Drummond R. Mass casualties and triage at a sport- ing event. Br J Sports Med. 2002;36(2):85–88; discussion 8.

95. Friedman LJ, Rodi SW, Krueger MA, Votey SR. Medical care at the California AIDS Ride 3: experiences in event medicine. Ann Emerg Med. 1998;31(2):219–223.

96. Smith FW. Where is the crowd doctor? Br J Sports Med. 1998;32(3):198.

97. Trites P, Stephenson D. Preparing a field hospital for a “mass” gathering. Can Nurse. 1984;80(11):48–50.

98. Banner G. The Rhode Island Medical Emergency Distribu- tion System (MEDS). Disaster Manage Response. 2004;2(2):53– 57.

99. De Lorenzo RA, Boyle MF, Garrison R. A proposed model for a residency experience in mass gathering medicine: the United States Air Show. Ann Emerg Med. 1993;22(11):1711–1714.

100. Galante JM, Jacoby RC, Anderson JT. Are surgical residents prepared for mass casualty incidents? J Surg Res. 2006;132(1):85– 91.

101. Goldman B. Spectator events: medical preparation a must. Can Med Assoc J. 1988;138(2):164–165.

102. Madge SN, Kersey JP, Murray G, Murray JR. Are we train- ing junior doctors to respond to major incidents? A survey of doctors in the Wessex region. Emerg Med J. 2004;21(5): 577–579.

103. Mann NC, MacKenzie E, Anderson C. Public health prepared- ness for mass-casualty events: a 2002 state-by-state assessment. Prehosp Disaster Med. 2004;19(3):245–255.

104. Rubin AL. Safety, security, and preparing for disaster at sporting events. Curr Sports Med Rep. 2004;3(3):141–145.

105. Rutherford WH. The place of exercises in disaster management. Injury. 1990;21(1):58–60; discussion 3–4.

106. Michael JA, Barbera JA. Mass gathering medical care: a twenty- five year review. Prehosp Disaster Med. 1997;12(4):305–312.

107. Arbon P. Mass-gathering medicine: a review of the evidence and future directions for research. Prehosp Disaster Med. 2007;22(2):131–135.

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