Best Practices: Mass Gathering Events

This is the season for large scale public events celebrating all that is great about our country. Many of these events will require some degree of EMS coverage, whether by statutory regulation, choice of the event sponsor or the authority having jurisdiction where the event is planned to occur. Guidelines for delivery of emergency medical care at public events can be found in the National Association of EMS Physicians soft cover book entitled Mass Gathering Medical Care: The Medical Director's Checklist, which I wrote with two colleagues several years ago. It is available through NAEMSP for a reasonable price ($20 for members and $35 for non-members).

Go to www.naemsp.org/products.html for further information and ordering instructions. The book is about 50 pages in length and is quite comprehensive. However, it is lacking a chapter on taking care of your own people. This was an unintended oversight and will be corrected whenever we decide to write an updated version. Clearly, this concept is a priority at all emergency incidents regardless of their nature.

I recently provided medical oversight at the 2006 Pro Cycling Tour in Philadelphia. This is the 156-mile professional bicycle race that goes up the Manayunk Wall. Despite the fact that I wrote the book on the subject and that I participate in Philadelphia-area mass gatherings as the EMS Medical Director several times every year, I violated several of the principles you are about to read below. When the Event EMS Director asked me at the end of the day how I let myself get sunburned, I realized that this was a good opportunity to talk about these concepts. Hopefully, those of you involved in similar events this summer will be able to avoid making the same mistakes. While the points below may seem like common sense, I am willing to bet that EMS personnel who staff special event EMS sectors more often than not are noncompliant with these principles.

1. Get a good night's rest prior to the event.

It is important for personnel to be awake and alert at events which may require rapid decision-making, walking or running distances and caring for large numbers of patients. Sleep deprivation produces a state similar to being hung over. You can never quite recover during the next period and you feel rotten the entire shift. Studies of physicians during their residency training has shown that sleep deprivation contributes to a greater number of medical mistakes and a greater risk of self-injury from driving sleepy, etc.

2. For outdoor events, use/provide sun block and insect repellant as needed.

Sunburn and mosquito bites are almost totally preventable causes of injury among EMS providers at mass gatherings. Repetitive sunburn is a major contributory factor to the risk of development of malignant melanoma later in life. Dermatologists claim that we have yet to see the epidemic of this disease due to the "suntan crowd" which became prevalent in the 1970s and 1980s. Sun block with an SPF of at least 30 (and preferably higher) should be applied to any areas of the body not covered by clothing at least one hour prior to sun exposure. I believe that I became sunburned rather quickly at the bike race because the command vest I was wearing reflected additional UV rays from my thorax onto my face.

Mosquito bites used to be just a nuisance. However, there are now several complications related to skeeters that are a risk for everyone who is a recipient of their feeding frenzy. We are seeing more abscesses today than ever before in emergency departments. Many of these are caused by methicillin resistant staph aureus (MRSA). Abscesses are complications of skin infections from any break in the skin including insect bites. Mosquitos also carry the west nile virus which causes encephalitis and can be fatal, although this is rare. Mosquito repellant should be generously applied to skin and clothing if you are working in an area of concern. However, be aware that DEET, the active ingredient in insect repellant, can cause seizures in high concentrations, so liberal use should be interpreted reasonably.

3. Hydrate hourly, especially in warm climates. Avoid caffeinated beverages.

Dehydration is not uncommon among emergency services workers who typically put the concerns of the patients or the incident above their own health. The obvious remedy for this condition is adequate hydration prior to and during the course of the incident. Prehydration is typically possible only at planned incidents such as mass gatherings or when cycling into a shift at long duration incidents. Thus, a plan for ongoing hydration should be followed. Generally, personnel should drink water at least every hour in hot and humid climates or when they are performing heavy workload. Electrolyte replacement becomes necessary only when there is no consumption of foodstuffs which contain them or when the body's solute losses are excessive, such as when the temperature exceeds 85F or at long duration incidents.

Caffeine is a drug and its use leads to dehydration through diuresis, a known therapeutic effect. Thus, consumption of caffeinated beverages, while tasty, is not in the best interest of your bladder at special events in which the bathroom facilities may be less than adequate, desirable, or available, especially given the potential workload for EMS.

4. Eat healthy and sensibly. Do not overeat.

Most importantly, avoid overeating. EMS providers need to be ready to leap into action at a moment's notice. Over consumption of calories at mass gathering events is a recipe for fatigue, sleepiness and feeling ill. Remember the saying, "Everything in moderation." Fried foods, junk food, and foods high in sodium should be shunned in excess. Salt intake is associated with thirst due to creation of a high solute concentration in the bloodstream which must be diluted by free water. Then, salt is discarded through the urine, so salt intake leads to the need to void. Consider bringing your own food so that the choices are better. It is usually cheaper anyway. Otherwise, make sure to carry the food pyramid with you on duty (just kidding!).

5. Plan to wear clothing which allows you to adjust to changing temperatures.

I showed up to the bike race in June wearing EMS shorts and short sleeves, waiting for the 80 degree temperature that never materialized. The temperature in the morning was in the 50s and I was cold. Whether you bring layers of clothes that can be removed as the temperature increases or you roll up your sleeves, you should have a plan to react to changing environmental conditions. Such a plan includes availability of foul weather gear and a change of clothing should it become contaminated by blood/body fluids, debris, food or other substance.

6. Use the bathroom prior to the event.

Once you are on duty the public expects that you are ready and able to serve them. While the time in the bathroom itself may only be a few minutes, the time looking for or traveling to or from the bathroom may be significant depending on the event characteristics. More importantly, you will be much more comfortable and less distracted if you do not feel the need to use the bathroom.

7. Stretch prior to assuming duty. Maintain some degree of physical activity but avoid being on your legs all day if possible.

A brief period of calisthenics prior to beginning the event coverage, even if this is not done formally, may help you to reduce the chances of becoming injured from sudden forceful adjustments of muscles during emergency response or patient care. This "limbering up" does not need to last more than five minutes and can easily be done as a group exercise or individually. The goal is to loosen up back, leg, shoulder and abdominal musculature as well as to wake you up and get you in the mood for service delivery.

This list is a start and is by no means comprehensive. Think about these points this summer, have fun and be safe. If you have interesting stories about your experience with major events, consider sending them to EMS Magazine.

Dr. Jaslow is a board certified emergency medicine physician fellowship-trained in EMS and Disaster Medicine. He is the Chief of the Division of EMS, Operational Public Health and Disaster Medicine and Co-Medical Director of the Center for Special Operations Training within the Department of Emergency Medicine at the Albert Einstein Medical Center in Philadelphia. Dr. Jaslow is also the Medical Director and Lead Physician for the Pennsylvania Task Force-1 Urban Search and Rescue Team and an active firefighter/paramedic and EMS Medical Director in suburban Philadelphia. He currently serves as the Medical Editorial Consultant for EMS Magazine and as a member of the editorial board for Advanced Rescue Technology. He can be reached at jaslowd@einstein.edu.