The classic definition of a mass gathering is a group of greater than 1,000 people (1,2,3,4), although the vast majority of the literature deals with groups exceeding 25,000. In this chapter we define a mass gathering as a group of people who have come together in a particular location for a specific purpose for a period of time that may range from a few hours (in the case of a sporting event or concert) to a few weeks (in the case of the Olympic Games).

Mass gatherings are extremely common all around the world. In the United States alone, 165 million people attend NBA, NFL, and NCAA events (5,6) and 5.5 million attend NASCAR events (6,7), only a fraction of the mass gatherings that occur each year. Only a relatively small body of literature covers this topic, however, and it has just been over the last 15 years that more has been written on the subject. Weaver stated in 1989 that there are “few data from which to plan emergency medical needs for public events and no recognized standards or guidelines for providing emergency medical services at mass gatherings” (3,8). The majority of what has been published is descriptive papers of various events, and not until recently has there been an attempt to define the medical planning needed for mass gatherings (9,10,11,12,13).

Whenever a large group of people gather, there is a risk for catastrophe. The responsibility for public health protection falls squarely on the event planners. The concerns of all parties, from public utilities, public safety, and hospitals to the event attendees, are best addressed during the planning of the event.

This chapter outlines the necessary steps in preparing and implementing medical care for a mass gathering as well as the essentials of planning for mass casualties and terroristic events. The roles of local fire, police, and emergency medical services (EMS) are described, and the groundwork for planning is discussed. There are also a multitude of variables, often uncontrollable, which must be taken into account. Many of these, such as environmental hazards and physical and ecological barriers, are also described.

The first step in planning an event involves assembling the event planning committee, which should occur well in advance and involve the event coordinator, designee from public safety, the local fire department official, and the medical director. In the initial meeting, the chain of command should be established as well as how information will be transmitted.

The event coordinator heads up the committee. Through this person, key information regarding the logistics and financial support for the event should be readily available. Either the local police department or a private security company will likely supply the public safety component of the event. The role of this organization is defined later as we discuss each stratum individually. Fire protection will likely fall under the auspices of the local fire marshal. Medical coverage concerns will be relegated to the person designated as the medical director. Together this committee will deliberate to form the basis for the preparedness plan.

The role of the local law enforcement agency or the employed private security company needs to be clearly defined. They should be in control of access to the event and involved in the development of the disaster plan. Crowd control is an essential area that will fall under their jurisdiction. Access to and from the event will, at times, be difficult due to masses of people, and preplanned entry and exit routes for emergency vehicles must be secured. Public safety should also be available if the need arises to control unruly patients or crowds.

The local fire service will have a vested interest in fire safety for any event, especially an indoor one. The structure of the established fire response system needs to be taken into account when developing the disaster plan. The local fire marshal will be able to supply information regarding the planned response to the event location and should be made aware of any potential fire hazards caused by the event, numbers of expected spectators, and planned access routes to and from the event. The fire department must be aware of hazardous materials such as pyrotechnics as well as chemicals that may be present in large quantities for cleaning or special effects. The fire department will need to know who will be in charge of the
event and negotiate the role of their department in the event of fire or mass casualty incidents.

Many fire departments utilize the incident command system (ICS), which offers a defined structure of who will be in charge of the scene at a mass causality incident. In this system, a command center is established. Large events with an established disaster plan risk adding to the chaos if the role of the event staff is not clearly defined beforehand. The medical director should negotiate a position in the command center as the medical consultant and coordinate the use of the established medical event staff with the incoming medical response from the local EMS agency and fire department first responders.

During the initial meeting with the event coordinator, the financial support for the medical team needs to be defined. Events held for profit should have resources available; nonprofit functions may not. Some hospital groups provide the medical support for events for an equivalent value in advertising. If resources are not available or are insufficient, donations from sponsors should be sought out. Medical supply companies or medical equipment companies might be willing to donate supplies or loan equipment for little more than advertisement at the aid station. The opportunity for local hospitals or community groups to show support for community events will encourage their involvement. Another option, which has not been commented on much in the literature, is to provide fee-for-service care.

The event medical director has many aspects to consider in planning for a mass gathering. Details include staffing, finance, communications, and logistics. Additionally, aspects of the event, such as estimated attendance, the type of event, weather, and the presence of drugs or alcohol, must be considered. Many of these variables cannot be predicted or controlled accurately but must be planned for as their presence becomes evident.

The characteristics of the planned event site need to be clearly defined. Will the event be indoors or outdoors? If the event is planned for indoors, items such as access routes significantly change. Indoor event planners need to consider ventilation in case of fire or the dispersion of hazardous chemicals by terrorist attack. Evacuation plans for the building need to be reviewed and incorporated into the disaster plan. Locations of the established first aid stations need to be defined in indoor arenas early in the planning sessions because they often cannot be moved. How will patients be taken to the aid stations when the seats are filled? Planned routes of travel need to be laid out and protected by security.

Outdoor events, conversely, allow for the movement of the aid stations to fit the need of the particular event. Outdoor events aid stations should be located within a walking distance of 5 minutes for the average anticipated spectator or at least no further than 1/8 mile apart (9). In outdoor events, barriers of both an environmental and physical nature exist and are subject to change with the influx of spectators as well as the weather. Once easily traveled paths may become blocked by masses of people or by water from overflowing streams and ditches during heavy rainfall. Once again, safe passage for emergency personnel needs to be planned early and protected by security. The area where medical care is provided needs to be clearly defined. What about the people in the parking lot? Will medical personnel be responsible for the participants in the event and the event support staff or the spectators only? This needs to be discussed in the initial planning session. If medical personnel will be responsible for the support staff, the medical teams need to be represented when the first of the staff arrive and stay there until the last of the cleanup crew has gone for the day. If they are responsible for the parking lot, an aid station may need to be positioned there as well.

Once the venue for the event is defined, the next appropriate measure is to visit the location. Detailed maps should be created paying close attention to environmental and physical barriers to passage. Potential hazards should be noted. For example, events occurring near wooded areas could pose hazards like snake bites or bee stings, and for indoor events, the concern for fire safety and ventilation becomes more important. Vital information can be attained from those who have provided care at the event during its prior engagements as to how the crowd tended to gather, the demographics of the attendees, and the numbers of requests for medical assistance. This information will be helpful in estimating the placement of aid stations and the needed level of coverage, including the number of aid stations and supplies that may be needed.

An article by Nordberg describes a general classification system for events. This classification system uses somewhat broad strokes to describe the general event venue and crowd activity and geographical layout. Class I events include those where the spectators all have seats and are generally stationary. Sporting events and concerts that have a short time period, in terms of hours in which they occur, are examples. Class II events consist of mobile crowds of people, who themselves may also participate in the event. These events occur over a period of time defined by days. Examples of these types of events would be Mardi Gras in New Orleans and the World’s Fair. Class III events are smaller in terms of crowd size but cover a large geographical area. Marathons and road bike races represent these types of events (14).

The demographics of the crowd play an important role in planning for medical coverage. Some events may attract a wide demographical cross section, whereas others may attract a narrower segment of the population. For example, a visit by the pope (15,16,17,18) will attract an older population, in general, and a hard rock concert will bring an entirely different subset of people (19). Sporting events will attract spectators of all ages and physical abilities. Having knowledge of these typical crowds that specific event types attract can help predict the types of medical issues that might arise. One should be able to predict that mosh pit activity (where participants are hurled around inside a ring of participants) will likely be present at certain popular rock concerts, resulting in increased medical utilization rates (MUR) (20) and a higher percentage of trauma. Political events have their own inherent issues and pose the increased risk of a terrorist attack. High-ranking political officials often attend these types of events and come accompanied by their own medical staff and security. These VIPs need to be known
as early as possible, and how their staff will fit into the overall medical care picture needs to be well defined. Some papers in the literature have attempted to define the “mood” of the crowd (6). This seems like a logical parameter to define; however, the mood often develops after the beginning of an event.

At Woodstock in 1994, for example, the mood changed significantly over the course of the multiple-day event (6,21,22). It started out as aggressive as people were trying to stake out their territories. After the rains, however, people began to help each other, and there was much more of a sense of community.

The next item to consider is the level of service that medical personnel will provide. The event coordinators may dictate this or it may be left for medical people to decide. This topic has spurred much debate in the literature. It seems clear, however, that there must be, at the very least, the input of a physician and usually one on site during the event itself (23). Also, regardless of the level of care, all possible efforts must be made to provide defibrillation to cardiac arrest victims within 5 minutes (10). This may be accomplished through the use of AEDs or carefully placed advanced life support (ALS) units.

The options for level of service provided can be divided into three broad categories: basic, intermediate, and advanced. Basic level service consists of basic-level EMTs and first responders. With this level of service, the care provided is limited to the provision of basic first aid, CPR, wound care, and it excludes the dispensing of medications. A physician medical director is required to develop protocols for treatment, disposition of patients, and quality improvement review. There should be provisions made for the presence of an ambulance on site or on call for those patients who require transport off site. Intermediate-level service should provide EMTs and nurses who possess the proper license to administer IV fluids and utilize some advanced airway devices. The physician may be present at the main aid station or may include these therapies in the protocols developed for this level of service. If the physician is not on site, there must be provisions made for the field crews to contact an online medical control physician. The therapies provided for in the protocols, especially with regard to dispensing medications, will be dictated by the limits set by the individual state boards of EMS. The question of who will be allowed to disposition patients must be clarified. Will the nurses and EMTs be allowed to release patients to the event or to home, for instance (24)? The option for an on-site ambulance still remains open at this level of service, but with advanced skills being performed on site, one would be preferred. An advanced-level service requires the continuous presence of a physician at the main aid station. Field crews should consist of paramedics, RNs, and physicians. The protocols developed are only limited by the physician’s license. This system allows for on-site treatment of minor illness and injury and the potential for the patient to be released back to the event. On-site immediate ambulance transport should be provided with at least one ambulance on site at all times. Quality improvement review of this system should be more rigid, and all dispositions should be overseen by a physician.

Several reviews have analyzed the number of staff needed for adequate coverage of mass gatherings. One, adopted by the American College of Emergency Physicians, states that there should be one EMT/nurse team per 10,000 attendants and at least one physician per 50,000 people (9).

One common misperception of many event planners is that the local EMS service will be capable of supplying adequate coverage to the planned event without special arrangements. This expectation often falls short of what is required because the local EMS system could be easily overwhelmed or not immediately available when the call goes out. To prepare for an event adequately, a specific level of care at the event must be established and developed in conjunction with the local EMS organization. Once the level of service has been determined, the infrastructure can proceed in development. The event medical director should serve as the on-site physician or the lead physician at the event if multiple physicians will be present. All members of the medical team should have the appropriate licensure and malpractice coverage. Protocols and/or standard operating procedures should be developed and supplied to all providers of medical care at the event. These should include a standard method of providing a disposition for patients. Whether the level of service is basic life support (BLS) or ALS, the goal should be to provide rapid and efficient quality medical care. Many patients seen for medical attention can be treated and released back to the event.

The level of care is often dictated by what is locally available and what the event planners can afford. A basic structure that can be easily modified to fit the particular need of a specific event and will work for either an ALS or BLS system is described here. This structure centers on a base station, which will serve as the center where the highest level of medical care will take place and the center for communications. The base station should house the on-site physician, the communication center, all supplies needed at the event, and the most sophisticated treatment center that can be put in place. It should be adequately equipped to initiate treatment for all medical emergencies including cardiac and respiratory emergencies and provide the basics of advanced trauma life support. This should include advanced airway equipment and the necessary tools to treat acute traumatic injuries. When providing care at smaller events, this is likely all that will be needed.

The staffing of this station should consist of the physician and two to three support persons (EMTs or nurses). This will allow for adequate medical care at the center with some ability to respond away from the center to treat patients in the crowd or retrieve patients to the treatment center. In situations where increased coverage is needed, the base station should house all terminal supplies in sufficient quantity to restock satellite stations. When the need for expanded coverage is required to minimize response times, the decision to utilize roving units or fixed position secondary stations must be made. It is recommended that if spectator density is the limiting factor in response times, roving units on foot, on bicycle, or in a golf cart should be utilized. When the event is to cover a large geographical area, secondary stations may be more appropriate because they can provide basic medical care up to and including some basic procedures. This will allow simple treatments to be provided with minimal disruption to the individual patient’s participation in the event. The care at these stations should be limited to short treatments such as sutures and minor wound care and tetanus prophylaxis and dispensing of medications. Treatments that may require longer to provide and may require a short period of observation and reevaluation can be initiated at the sec
ondary station, and then the patient may be moved to the base station where a final disposition can be made by a physician. The base station should serve as the point from which all patients are transported away from the event unless the nature of the emergency prohibits it. This scheme will reduce the confusion often associated with locating a single patient in a crowd of thousands and provides the need to maintain a single route of entry and exit for emergency vehicles.

This setup is a useful base model to use because it lends itself to expansion or downsizing according to the size of the event for which coverage is needed. Frequently the same organization will be called on to provide medical coverage for multiple events of various sizes and types. The system can be further expanded to include multiple base stations when there is a physical barrier that is impassable such as a race track, which may require a base station on either side of the track. As the system expands, there will be the need for a runner to resupply secondary stations and retrieve supplies from an offsite location as needed. The secondary stations should be staffed by two to three people, which will allow for a member of the team to be dispatched to an individual in the crowd while leaving someone at the station. Response from a secondary station may be accomplished either on foot or in a golf cart, depending on the physical layout of the event. The medical event staff should be assembled and briefed weeks prior to the start of the event. They should be trained on the protocols and standard operating procedures that will be used. The arrival times for the medical team should be well defined, and an assembly point should be established from where teams can pick up supplies and be dispatched to the secondary stations. The base station serves this function well. A uniform dress code should be established that will allow medical personnel to be easily identified. Provisions for the medical team should include parking passes, appropriate tickets or passes to the event, and food coupons.

Communication during a mass gathering is a crucial point that must be well delineated and ideally have some degree of redundancy. The failure of communication can destroy even the most well-planned event coverage. In the event of a disaster, communication among the medical staff will need to be intergrated to all other aspects of the public safety model. The broad availability of cellular service has improved this aspect of event coverage significantly. The communications center should be the base station, which should have the capability of communicating with all aspects of public safety including the local fire department, local EMS, police or security, and event administration as well as individual medical staff. This is often best accomplished through the use of two-way radios or cellular phones with similar capabilities. Hard line or cellular service should also be available at the base station. The physical layout should be defined during the initial event planning in such a way that the crowd can be divided into specific locations in order to narrow the search area for any specific individual during the event. All calls for assistance from the crowd should be coordinated through the base station, which will then in turn dispatch the appropriate medical team. Even if a spectator reports an emergency to one of the secondary stations, the base station should be notified prior to the initiation of a response.

Provision of medical care at an event is not without liability. Thus there is a need for adequate documentation of all patient encounters. The documentation of any medical care provides medicolegal protection as well as an avenue of data collection and allows for reporting of the service provided back to the event coordinators. If fee for service is to be used, the level of documentation should allow for optimized billing and reimbursement. A method of documenting patient encounters must cover the scope of potential patient complaints without being overburdening on the individual provider. The person requesting an aspirin certainly does not require a full history and physical exam (H&P) like the patient presenting with chest pain. The patient requesting aspirin likely only requires name, age, sex, complaint, allergies, and his or her function at the event. The patient with chest pain will need a full H&P similar to what would be done in the emergency department. The form developed must be simple to fill out but provide adequate medical documentation of the complaint, exam, assessment, and treatment given. Refusal-of-care forms and AMA forms must also be established and in place at the event (10). Basic discharge instructions should also be provided for those treated at the event, and there will need to be a system of quality improvement review to improve care for future events and for risk management purposes.

After the event is over, all the medical records should undergo analysis and the information should be compiled. The event coordinators will appreciate a postevent report, including the number of patients treated, the types of medical complaints encountered, the treatment provided, and the disposition of the patients. This postevent analysis serves many functions. It provides information for future event coverage of similar venues, allowing for minor adjustments in staffing and equipment needed. The event coordinators will be able to better appreciate the role of the medical team at their event, keeping in mind that many people who would otherwise have had to leave the event to seek medical attention were able to remain and continue to participate. Data collection will also serve as an invaluable research tool allowing for publication of the experience gained at the particular event. Finally, the data will be useful as the primary tool for quality improvement review of the coverage provided. Letters thanking those who have participated in the medical coverage of the event, either physically or financially, should be sent in an effort to encourage their support in the future. Letters from patients treated at the event should be forwarded to the event coordinators. All of these postevent efforts will serve to justify the presence of the medical team and solidify its position at future events.

Much can be learned from prior events. A review of the literature (Table 26-1) makes evident that medical usage rates (MURs) vary widely, from 3 patients per 10,000 (PPTT) in a 5-year review of concerts in Southern California (19) to 347 PPTT at the 1989 Special Olympics (9). Seventy percent of events reviewed had an MUR ≤70 PPTT. Multiple factors need to be taken into account when trying to predict MURs, such as type and duration of event, attendance, mobile versus seated, indoor versus outdoor, weather, physical plant, alcohol and drug usage, and age and mood of the crowd.

Several of these factors have been shown to correlate with higher MURs (6):

Although many other variables may intuitively point toward higher MURs, the reported data have been inconclusive.

In a review of the literature describing mass gatherings during which mass casualty incidents or terroristic events have taken place (25,26,27), there have been several success stories. What is evident is that although the majority of medical care at mass gatherings will involve taking care of spectators and participants, it is crucial to have a mass casualty plan that can be activated if necessary. This plan should ideally be based on “daily routine doctrine,” whereby the disaster plan puts into effect an escalation of existing treatment protocols (27).