NAEMSP POSITION PAPER: MASS GATHERING MEDICAL CARE DAVID JASLOW, MD, MPH1 ARTHUR YANCY II, MD, MPH2 ANDY MILSTEN, MD3 FOR NAEMSP COMMITTEE ON STANDARDS AND CLINICAL PRACTICE JANUARY 2000
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Temple University Division of Emergency Medicine, Philadelphia, PA Emory University Department of Emergency Medicine, Atlanta, GA University of Maryland Division of Emergency Medicine, Baltimore, MD
Correspondence to: David Jaslow, MD, MPH Temple University Division of Emergency Medicine 3401 North Broad Street, Philadelphia, PA 19140 (215) 707-1575 FAX: 215-707-3494 e-mail:
[email protected]
2 Mass gathering medical care refers to organized emergency health services provided for spectators and participants at events in which 1000 or more persons are gathered at a specific location for a defined period of time.1 The delivery of emergency medical care at mass gathering events is uniquely challenging in several ways. EMS personnel must navigate large crowds of people who may be densely packed into selfcontained clusters or who may be located in discontinuous areas without clear landmarks. Frequently, barriers to access prevent the use of motorized transport vehicles for ingress to or egress from the region in which the patient is located. Environmental factors, such as weather, can impact upon the patient’s illness and can contribute to large numbers of ill patients within a short time span. Failures of communications systems and a lack of available resources may lead to delays in patient access during mass gathering events. Increasingly, the concern for terrorist incidents and multiple casualty events at large public gatherings has caused EMS planners to rethink their human resource and equipment deployment strategies to better prepare for a catastrophe. In summary, the typical mass gathering event medical emergency, while still likely to be a common problem, may present itself in a fashion quite different than what most EMS providers are used to encountering in their communities. Emergency medical care has been provided at such events in the United States for at least the last 30 years.2 A review of the medical literature indicates that the sophistication of the delivery systems for this care has improved dramatically since the 1960s, when volunteer physicians and other health care professionals assisted demonstrators at large anti-war demonstrations and outdoor concerts. However, only select events have been described in the literature. These events were located in urban areas with large population centers or involved very sizable populations and detailed event planning. Despite a volume of literature that numbers over 100 articles, there is no uniformity or standardization of mass gathering medical care at different venues across the country. Many case reports exist that describe both preparations for patient care as well as the numbers and types of patients encountered at a few of the larger or more high profile events in the last three decades. However, the vast majority of mass gathering events has never been evaluated from the standpoint of the adequacy of delivery of emergency health services. Nor has there been any significant scientific review of variables or characteristics related to patient generation at mass gathering events. Not surprisingly, a recent review of state legislation on mass gathering medical care regulations produced only six examples nationwide.3 While various authors of the mass gathering medical care literature have discussed proper planning and response to these events, only ACEP has published an official guide for those planning the delivery of emergency health care.4 This document was a milestone when it first appeared in 1990. However, it deserves to be updated for several distinct reasons. First, the format of the document is not designed as an easily referenced checklist. Second, the paper is written in a lay style that lacks the depth and breadth necessary to provide today’s EMS professionals with practice guidelines for mass gathering medical care. Third, it fails to offer significant information about communications systems, medical oversight and public health. Such a comprehensive document that provides guidance for all elements of planning for emergency medical care at a mass gathering event is the goal of this position paper.
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3 NAEMSP recognizes that there may be significant variation in the specific approaches to EMS delivery at large events. However, there is a need to define minimum standards for the delivery of such care which should be met by all event sponsors and Event EMS Coordinators, regardless of geographic location, event size or resource availability. The medical director of a mass gathering event is responsible for ensuring that the provision of emergency medical care meets or exceeds the standard of care for the surrounding community. Additionally, he/she must lay the foundation of understanding and agreement with event managers, venue owners and the Event EMS Coordinator regarding the planning and execution of a successful emergency medical operation. The discussion with event managers and/or venue owners should result in an agreement covering the elements listed in this document. Its form should be contractual and its contents specifically detailed on paper due to the risk management and medicolegal implications of the anticipated duties. NAEMSP also recognizes that there is a significant lack of scientific evidence to substantiate many of the points included in this document. Since there are no prospective studies in the mass gathering literature, the points highlighted in this position paper are derived from application of a systems approach to mass gathering event medical care. The systems approach espouses a “whole is greater than the sum of their parts” philosophy. Thus, the delivery of emergency medical care at a mass gathering event is dependent on coordinating the complex interrelationships of a number of functional components and attention to detail among many operational sections. The centerpiece of this effective medical response is the medical action plan, a blueprint for the delivery of emergency medical care. It contains a compilation of subplans each of which addresses a different facet of medical care operations or administration. The primary mission behind development and execution of a medical action plan is to ensure that important goals and objectives related to the delivery of emergency medical care would be met. The basic building blocks of a medical action plan appear below. They are listed in chronological order beginning with elements that must be addressed in the weeks to months prior to a planned event. These points are meant to serve as a guideline to aid in the effective planning of emergency medical care delivery. A detailed description of each subcomponent of the medical action plan, as well as a brief synopsis of the individual section, may be found in a document entitled Mass Gathering Medical Care: The Medical Director’s Checklist, which is available through the NAEMSP office.
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4 NAEMSP Position on Mass Gathering Medical Care A medical action plan must be created and enacted for every mass gathering event to ensure that timely and appropriate emergency medical care is available to all spectators and participants. Such a plan must adhere to all local, regional and state regulations regarding mass gathering event planning and must be endorsed and approved by the Event EMS Coordinator and the Event EMS Medical Director. A medical action plan must be comprehensive and proactive in nature and will address the following 15 components: •
Physician Medical Oversight The physician medical oversight component defines minimum recommendations for the position of Event EMS Medical Director and its requisite job requirements.
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Medical Reconnaissance The purpose of medical reconnaissance is to gather crucial information that will aid the Event EMS Coordinator and the Event EMS Medical Director in planning the successful response to medical emergencies through careful analysis of elements related to morbidity. The medical reconnaissance component lists these elements and other factors that must be addressed in order to develop an effective emergency medical response.
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Negotiations for Event Medical Services Negotiations for event medical services must involve the event administrators, the Event EMS Coordinator, and the Event EMS Medical Director. These parties must discuss and agree on all aspects of the medical action plan. A brief but important list of objectives is provided to guide these discussions.
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Level of Care The level of care component defines the minimum emergency medical care capability as the EMT-Basic level. Sophistication of the medical sector should mirror that within the local community, but will ultimately depend upon event characteristics and available resources.
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Human Resources The human resources component defines numbers, roles and responsibilities of medical personnel and logistical issues surrounding their deployment.
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Medical Equipment The medical equipment component defines the types of medical equipment necessary to handle anticipated patient conditions and provides suggestions for its deployment.
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Treatment Facilities The treatment facilities component defines the need for and planning of on-site and off-site definitive care.
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Transportation Resources The transportation component defines how emergency and non-emergency transportation resources will be deployed and utilized.
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Public Health Elements It is desirable to protect the health and well-being of participants and spectators from infections and unintentional injuries related to improper food, water, waste, land and/or road/traffic management. The public health component defines how the medical sector should interface with the jurisdictional public health director to accomplish these tasks and what topics EMS personnel should be educated about concerning EMS and public health.
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Access to Care The access to care component defines methods that patients should use to obtain emergency medical care. It also provides guidelines for the medical sector in order to minimize barriers to that care.
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Emergency Medical Operations The emergency medical operations component addresses key operational details central to successful delivery of emergency medical care, including planning for mass casualty incidents, disasters and response to hazardous materials/terrorism incidents.
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Communications The communications component defines how to develop an efficient system to link patients to emergency medical resources.
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Command and Control The command and control component provides information to assist in the formulation of an organizational structure to guide the provision of emergency medical care.
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Documentation The documentation component stresses a uniform approach to the recording of patient care information for medicolegal, risk management and research purposes.
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Continuous Quality Improvement The continuous quality improvement component includes information relevant to improving the delivery of medical care through analysis of medical sector performance.
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6 REFERENCES 1. DeLorenzo RA: Mass Gathering Medicine: A Review. Prehospital Disaster Med 1997; 12(1): 68-72. 2. Chused TM, et al: Medical Care During the November 1969 Antiwar Demonstrations in Washington, DC: An Experience in Crowd Medicine. Arch Intern Med 1971; 127: 67-69. 3. Jaslow D, Drake M, Lewis J. Characteristics of State Legislation Governing Mass Gathering Medical Care. Prehosp Emerg Care. 1999; 3(3): 316-320. 4. ACEP Disaster Medical Services Subcommittee. Provision of Emergency Medical Care for Crowds. ACEP. 1990 ADDITIONAL READINGS Baker WM, et al: Special Event Medical Care: The 1984 Los Angeles Summer Olympic Experience. Ann Emerg Med 1986; 15(2): 185-190. Binder LS, Willoughby PJ, Matkaitis L: Development of a Unique Decentralized Rapid-Response Capability and Contingency Mass-Casualty Field Hospital for the 1996 Democratic National Convention. Prehospital Emerg Care 1997; 1(4): 238-245. Boyle MF, De Lorenzo RA, Garrison R. Physician Integration into Mass Gathering Medical Care. Prehosp Dis Med. 1993; 8:165-168. Brunko M: Emergency Physicians and Special Events. J Emerg Med 1989; 7: 405406. Chapman KR, Carmichael FJ, Goode JE: Medical Services for Outdoor Rock Music Festivals. CMA J 1982; 126: 935-938. DeAngeles D, et al: Traumatic Asphyxia Following Stadium Crowd Surge: Stadium Factors Affecting Outcome. WMJ 1998; Oct: 42-45. De Lorenzo RA, et al: Effect of Crowd Size on Patient Volume at a Large, Multipurpose, Indoor Stadium. J Emerg Med 1989; 7: 379-384. Federman JH, Giordano LM: How to Cope With a Visit From the Pope. Prehospital Disaster Med 1997; 12(2): 86-91. Friedman LJ, et al: Medical Care at the California AIDS Ride 3: Experiences in Event Medicine. Ann Emerg Med 1998; 31(2): 219-223.
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7 Grange JT, Green SM, Downs W: Concert Medicine: Spectrum of Medical Problems Encountered at 405 Major Concerts. Academic Emerg Med 1999; 6(2): 202-207. Health and Safety Commission/Home Office/The Scottish Office: Guide to Health, Safety and Welfare at Pop Concerts and Similar Events. Crown Publishing 1993; London: HMSO: ISBN 0 11 341072 7. Hewitt S, Jarrett L, Winter B: Emergency Medicine at a Large Rock Festival. J Accid Emerg Med 1996; 13: 26-27. Hnatow DA, Gordon DJ. Medical Planning for Mass Gatherings: A Retrospective Review of the San Antonio Papal Mass. Prehosp Dis Med. 1991; 6:443-450. Hodgetts TJ, Cooke MW: The Largest Mass Gathering: Medical Coverage for Millennium Celebrations Needs Careful Planning. BMJ 1999; 318: 957-958. Kassanoff I, et al: Stadium Coronary Care: A Concept in Emergency Health Care Delivery. JAMA 1972; 221(4): 397-399. Leonard, RB: Medical Support for Mass Gatherings. Emerg Med Clin North Am 1996; 14(2). Michael JA, Barbera JA: Mass Gathering Medical Care: a Twenty-Five Year Review. Prehospital Disaster Med 1997; 12(4): 305-312. Nardi R, et al: Emergency Medical Services in Mass Gatherings: The Experience of the Formula 1 Grand Prix ‘San Marino’ in Imola. European J Emer Med 1997; 4(4): 217-223. Ounanian LL, Salinas C, Shear CL: Medical Care at the 1982 US Festival. Ann Emerg Med 1986; 15(5): 520-527. Parrillo S: EMS and Mass Gatherings. e medicine website Aug 1998; (emedicine.com/emerg/topic812.html). Parrillo S: Medical Care at Mass Gatherings: Considerations for Physician Involvement. Prehospital Disaster Med 1995; 10(4): 273-275. Pons PT, et al: An Advanced Emergency Medical Care System at National Football League Games. Ann Emerg Med 1980; 9(4): 203-206. Sanders AB, et al: An Analysis of Medical Care at Mass Gatherings. Ann Emerg Med 1986; 15(5): 515-519. Schulte D, Meade DM: The Papal Chase. The Pope’s Visit: A “Mass” Gathering. Emerg Med Serv 1993; 22(11): 46-49,65-75,79.
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8 Sexton PA, Burns RS, Lerner SE: Sunshine ’75: Rock Medicine Inside Diamond Head. Hawaii Med J 1975; 34(8): 271-275. Spaite DW, Criss EA, Valenzuela TD, et al: A New Model for Providing Prehospital Medical Care in Large Stadiums. Ann Emerg Med 1988; 17: 825. Thompson JM, et al: Level of Medical Care Required for Mass Gatherings: The XV Winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991; 20(4): 385-390. Whipkey RR, Paris PM, Stewart RD: Emergency Care for Mass Gatherings: Proper Planning to Improve Outcome. Postgrad Med 1984; 76(2): 44,46-48,51,54.
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