By John C. Lewis, Ed.D., EMT-IT
Every year, hundreds of EMS agencies across the country are called to stand by at football games, rock concerts, neighborhood block parties, and a host of public activities. Often, medic units and personnel are asked to set up first-aid stations at very small to extremely large gatherings, such as “Live Aid,” the “Million Man (and Woman) March,” untold numbers of fireworks displays, outdoor rock concerts, religious gatherings, political rallies, and the like. These events have the potential for stressing a system, developing into a large-scale mass-casualty incident, providing an opportunity for local terrorism, or simply being recorded as a pleasant day or evening of service.
Events may be public or private. Public events are defined as large-group gatherings celebrating or recognizing a holiday, an athletic tournament victory, a nationally visible bicycle race, a parade, or a municipally sponsored activity. Private events are operated by a for-profit group sponsoring a rock concert or similar event. There are combinations of these types of events and nonprofit-sponsored activities such as health fairs and church bazaars.
This article presents ways in which EMS providers can manage such events. All recommendations may not fit all departments and management structures, but the principles are the same regardless of the manner in which the services are delivered.
PLANNING FOR THE EVENT
Whenever possible, hold planning meetings for events far in advance. Determine the following information at the planning meetings:
1. Type of event (concert, controversial political rally, or marathon race, for example) and the role of the crowd (spectators or participants, for example).
2. Estimated size of the crowd.
3. Nature of the crowd—youth, young adult, elders, families, mixed group.
4. Time of day and estimated length of the event.
5. Anticipated special concerns—heat, cold, late hours, long line of march, prevalence of alcohol and drugs concurrent with the event, fanaticism.
6. Potential for violence or other case-related amplifier such as a controversial political or celebrity figure.
7. Vulnerability of the location for revenge-motivated activity including terrorism on a local or national basis.
What is well planned usually runs well. A few hours of forethought may prevent hundreds of hours of after-incident activity involving patients, families, providers. and the media. If the system “loses” one patient, all the good accomplished for many others will go unnoticed.
(1) Logistics of unit placement, patient tracking, and hospital destinations are important aspects of event management. (Photos courtesy of author.)
Following are elements to consider in the planning phase of events:
Identify a comprehensive site plan with aid stations well in advance of the event. Such plans include medic unit placement, communications, fire services, police, and special service areas.
There is no “magic formula” for determining the number of units to deploy; the best indicators to use are the history of previous events, weather predictions, and the nature of the event. Planners are encouraged to overestimate for one-of-a-kind events such as a papal visit, a political rally or march, or an incident that has never taken place in that locality. It is critical to include mutual-aid arrangements and interagency cooperation in the plan. Any city or town, regardless of how large and confident it may be, will be severely criticized if trouble occurs and there is no plan to supplement EMS response. Units may be held in reserve and called to respond if conditions warrant. Several state EMS laws or plans mandate minimum numbers of units to be available every day to ensure a specific response time to an “ordinary” emergency call. Events, however, are different, and municipalities need to experiment with proper levels of unit assignment. Take care not to overstress the existing system because of the event, thereby diminishing protection of a local area; this is the kind of situation that mutual aid was designed to accommodate. Make a record of answers to these kinds of questions: How did it go last July Fourth? What problems did we encounter? There were a million people on that pier and in the surrounding blocks—what can we do better if things go sour?
(2) Large-scale events often call for unit cooperation from several jurisdictions. Shown here are units ready for deployment along a 13-mile bicycle race involving several grueling laps.
(3) Keep first-aid stations as orderly as possible. Shown here is the effect that 100-degree-plus temperatures can have on providers.
Have a written and detailed description of the nature of the event distributed to event sponsors as well as EMS, fire, and police services providers. Prepare this document well in advance. It should clearly identify the elements that will be in place and their locations. Make every effort to avoid last-minute on-site changes that will cause real or perceived confusion. All units should be on-site at least one hour before the event is to start, since there are always those who arrive early to begin setting up, celebrating, or partying. This written agree-ment should also specify what steps to take if anyone discovers that conditions are beginning to deteriorate. Without exception, unless the plan is written and widely distributed, a vendor or other agency will set up por-table restrooms right where the system plans to erect its inflatable tent!
There must be a unit replacement contingency plan: Replace each unit on the scene immediately if that unit is used to transport a patient. The site commander must carefully monitor this situation; the resources available cannot be permitted to drop below an acceptable level of coverage. Unit availability can change almost instantly when things start to happen. The site commander during an event must be an EMS officer working closely with the fire and police command structure. The kind of difficulty you will encounter in an event will call for several medical teams and units ready to move quickly to treat unexpected numbers of victims. The ultimate combination of trouble, for example, has been seen during serious accidents at events such as air shows. Without a plan, this type of inherent disaster will escalate measurably. Experience has shown that a badly managed ticket or admissions procedure to a rock concert can have fatal results.
Holding an on-site meeting before the event begins is important. This meeting of everyone involved will reinforce communication protocols, medical command issues, unit placement, and last-minute changes. Here, event packets containing information regarding hospital locations, radio procedures, communications guidelines, food procurement processes, and the like can be distributed. A single telephone number that can act as a “help desk” will be very valuable to provider units coming in from out of town to cover a major event.
GUIDELINES FOR SUCCESS
Use the incident command system (ICS) as much as possible during an event. Or, if the event is being privately managed, an on-site municipality representative should establish an ICS should conditions deteriorate. The way to modify the system for an EMS event is simply to make the EMS site coordinator the incident commander and then parcel out roles of casualty transport officer, logistics, fire control, safety and security, and other sector operations. If a major fire occurs, incident command is shared with the ranking fire officer.
Provide all units with a radio capable of receiving and transmitting on all frequencies that will be used at the event. Use a single radio frequency to coordinate medical units on-site. If such an arrangement is not in place, rent an adequate number of radios for the duration of the event. Test them in advance to make certain that repeaters are not needed if the event spans a long distance, such as a marathon or a bike race. If at a location for the first time, conduct tests to make sure radio reception is not compromised. If there is a problem, use cell phones or other systems. Do not depend on dialing cell phone numbers to call units; such a process will undoubtedly result in a failure to communicate. Headsets for radios are mandatory, since many events feature loud noise from speakers that are inevitably placed near the communications unit. Have plenty of extra radio batteries on hand.
Assign advanced life support (ALS) and basic life support (BLS) units close to fixed first-aid stations, preferably in locations from which they can move freely throughout the site (if crowd conditions permit). In some locales, you can use golf cart-type vehicles; however, large and compacted crowds prohibit this type of application. Position “on-foot spotters,” such as members of an engine company or similarly sized group of EMTs, throughout the site; they should have portable radios and EMS jump kits, including defibrillators. One inexpensive way to identify the locations of the spotters or persons dispatched from a first-aid station to retrieve a patient is with a simple small strobe light mounted on a telescoping pole, such as the stick handles available for “light bulb snatchers.” These strobes are battery powered and take up little space. You can also save space by sending out teams equipped with rollup stretchers that can be spread out and neatly placed under patients. A grid map of the event site is absolutely necessary if the location is in any way complicated. If spinal immobilization is required (usually rare in most events), teams can radio to logistics for a rolling litter with a backboard and collar. You can save much time and exertion by going out for a patient without a lot of equipment. Teams can respond effectively with only a radio, oxygen, general first-aid jump kit supplies, small splinting material, a defibrillator, and a rollup stretcher.
In most cases, unless personnel numbers are abundant, no more than two members of a station should leave to retrieve a patient at any one time. They should provide communications with an initial condition report regarding the patient and then give progress reports every five minutes until the patient is returned to the station, picked up by a unit, or released by the retrieval crew. Spotters should be trained to identify potentially hazardous situations. Crowds will climb up and sit on almost anything to get a good view, but many of these locations have the potential for creating victims.
Physical placement of first-aid stations is important to the success of event EMS operations. On a preplanning map, situate stations so participants and providers do not have to travel far to access them. Space them no more than 100 yards apart, depending on the size of the crowd anticipated. Be sure to identify some blocked-off travel paths to allow for emergency vehicles and personnel to travel between stations and through the crowd. At large events, isolate these travel paths using portable metal guide rails or wooden barricades. Police assigned to the event must enforce the “emergency vehicle” nature of the lanes if at all possible. Stations should remain fully staffed with EMS personnel from units until the crowds have considerably diminished; frequently, injuries occur after the event is over and everyone is leaving.
The EMS site officer should monitor the number of cases and level of activity at first-aid stations and take steps to supplement standby medic units if warranted. Provide early notification if other units are to respond; it may take considerable time to respond to the event site if there are huge crowds. Remember that response time may increase dramatically if the event is just getting started and attendees are arriving by the thousands by car and bus.
If a decision is made to transport the patient to a hospital, the casualty transportation officer should determine the destination for each patient; for a mass-casualty incident, distribute patients equally among hospitals. Often, the tendency to overload one hospital unexpectedly results from a general feeling that “everyone is a minor injury.” Even minor injuries in large numbers can severely tax an emergency department in a very short time. Drug- and alcohol-related patients can spend a great deal of time in the ER. Some patients may even self-transport and clog the ER. The EMS officer should check periodically with the closest hospitals by radio or telephone to determine if the hospital is being overwhelmed with event cases. Ask returning crews how well an ER is faring under this kind of patient load. If the local hospitals do not have two-way communication with the dispatch center, provide them with a portable radio for the duration of the event. Single-direction communication cannot provide the necessary information needed during a special event. This valuable feature will help identify patient locations for family members and chaperones, especially for those from out of town. Additionally, issues of “consent to treat” will be facilitated by this kind of communication. At the very least, the parent or guardian will know where the charge has been transported. The system should be ready to transport these parents to the hospital by some means (a police or medic unit) to be reunited with their children.
Make sure BLS and ALS supplies are plentiful at each station. All stations need AEDs; full ALS kits may become scarce in major incidents. Whenever possible, staff and equip all response units to the ALS level. Special events generate the need for IV lines! Think also of simple adjuncts such as sanitary napkins and “sting stoppers”; know the location of pay phones and the local mass transportation stops, especially if routes have been modified because of the event.
Some record of treatment of each person seen at an event is necessary. You can use a simple form for adhesive bandage cases; but for each treat-and-release patient, record the nature of the complaint and the treatment. Complete a full trip report for those transported. Notify the communications officer or event clerk of the patient’s name and hospital destination. This information may prove to be invaluable if family and friends are looking for the patient later. Follow standard procedures regarding refusal of care and like issues whenever possible. Use white boards and laptops to track where units are going and when they left with the patient. It is a good rule to try to keep procedures for events similar to normal operating procedures as much as possible. Disseminate and follow standard lost-child (and adult) protocols; separated family members hundreds of miles from home can translate into anxious patients.
At larger events, implement a central name bank of persons treated and transported (with destination). The overall event management personnel can facilitate this process; it should occupy minimal EMS personnel resources. A simple transmittal of patient names to a central location could be converted to a laptop-based database that may be easily accessed when family or friends inquire. This kind of activity is especially critical during foot races, where runners are previously registered and given identification numbers. Require the response unit to report the runner number as soon as possible. This simple activity will eliminate many logistics and public information problems after the event is over.
Security of the stations is needed at events where large crowds are expected and mobility of response must be ensured. The perception that these stations may have large quantities of drugs may cause a potential violent episode if there is no evidence of security nearby. All stations should have at least one uniformed officer in attendance. Bicycle units are invaluable if equipped with AEDs and radios; they can maneuver easily with whistle-blowing cyclists in uniform responding. Large geographic area events may benefit from motorcycle EMS units equipped with radios and AEDs. Motorcycles can bypass parade routes and running lanes very easily and can be extremely valuable in receiving rapid response and reporting conditions to the communications officer.
Urge units that transport patients to limit their time at the hospital as much as possible, since the event may have severely stressed the system. Communications should contact the hospital by telephone if a medic unit is excessively delayed; likewise, instruct units to notify communications of such delays.
Weather changes can markedly change an event from simple to complex. Thunderstorms, lightning strikes, rapid temperature changes after showers, and snow can cause illness and injury. Plan to accommodate for this rapid change in conditions. Temperature changes from very hot to considerably cooler after rain will affect large groups of poorly prepared young people and can send large numbers of shivering children to first-aid stations. If that chance exists, consider using transit buses as temporary shelters. In some areas, lightning-monitoring systems should be available.
Practice good medicine in weather-related events. Do not be tempted to hose down the crowds in hot weather. Instead, have sprinklers and water bubblers open and available to those who wish to go under them—and they surely will. Event announcers can urge the crowd to cool off under the sprinklers whenever they want. But, in the worst case, heat stroke patients need more than a hose to bring them around appropriately. Be able to retrieve and monitor them quickly, start IV and oxygen therapy, and then transport them if warranted. Plan ahead to have everyone understand why it is a bad idea to “cool the crowd.” In addition, some people may be so angry about being wet down without permission that tempers may flare! Similarly, be ready to warm participants during winter parades. Cold presents its own set of concerns, and event medical providers should recognize symptoms of hypothermia.
Make certain that all transport vehicle drivers know the territory. There is little more embarrassing than to have an ambulance pull into a gas station and ask directions to the hospital. This can happen when units are secured from outside the jurisdiction of the event. Solve this problem easily by putting maps to all hospitals in the event packet distributed prior to the event.
Plan for the comfort of providers. Provide bathroom facilities, effective hand-washing and other sanitary needs, and food. Continuously clean hands at first-aid stations are obviously desirable; commercial preparations designed for hand cleaning when water is in short supply may be used. The plan document should identify restroom facilities for providers and the public; identify special facilities for providers only, for comfort and expediency.
PHYSICIANS ON SITE
Consider having a physician on-site as a valuable resource instead of as a care provider for every patient. BLS and ALS personnel are quite capable of treating the same types of injuries and illnesses they regularly encounter in daily nonevent responses. When possible, nonphysician providers at the station should greet the patients and determine the problem. Consult physicians according to an agreed-on protocol for first-aid stations and for on-site medical command. Conserve physician resources to make certain that patients with the most serious complaints are seen in a timely manner. Note: First-year residents do not usually make the best event physicians, especially during the first six months of that year. Residents with at least a year in service in an ER or those with prior EMS experience are ideally suited for this type of duty. In addition, physicians should not, in normal cases, go with a team to retrieve a patient. They can be much more effective if they stay with the first-aid station and let patients come to or be delivered to them.
The following are instances in which a physician at a first-aid station may be of great help:
1. Assisting in a “transport or treat-and-release” decision.
2. Major incident patient care—major broken bones, drug and alcohol interactions.
3. Patient education—beyond that provided by the EMT or paramedic, similar to that which patients may receive in an ER; they can be told to follow up with their family physician.
4. Patient care outside the scope and drug formularies of the providers is a highly appropriate use of physicians on-scene. Such physicians, however, should be reminded that they are practicing in a field scenario, not a real ER! They should well document any treatment and information they provide.
Similar to the uniformed personnel, on-scene physicians should look the part of medical professionals at an event. Casual clothes need to be exchanged in favor of vests, scrubs, or other clearly identifying apparel. This principle is especially true if and when it becomes necessary for the physician to negotiate through a crowd. As with all public safety personnel, professional appearance carries with it a degree of professional respect. If physicians look like participants in the event, no one will pay attention to them. Finally, physicians should understand that their role lies within the scope of their medical practice and with their position in an EMS system, not in the control of the event.
The key to successful event management and implementation lies in preparedness. Circumstances such as weather changes, uncontrolled vehicles, nail bombs, gang fights, domestic violence, panic, severe weather, and structural collapse dictate that we be well prepared and ready to respond.
John C. Lewis, Ed.D., EMT-IT, is a 30-year veteran of the fire and emergency medical services. He is currently medical officer for the Second Alarmers Association and Rescue Squad of Philadelphia, Inc. He served as chair of the EMS Department at the University of Maryland in Baltimore County, where he founded the first master’s degree in EMS. He was Philadelphia’s regional director of EMS as a member of the Philadelphia (PA) Fire Department.
