The World Health Organization defines a mass gathering as an event, organized or unplanned, where the number of people attending is enough to strain the planning and response resources of the host jurisdiction.1 The National Association of EMS Physicians frames its definition around the need for “organized emergency health services provided for spectators and participants at events in which at least 1,000 persons are gathered at a specific location for a defined period.”2
Examples of mass gatherings can include school events (sporting events, parties, large gatherings such as graduations) or community events (fairs, athletic events, foot and auto races, concerts and festivals, political events/protests, even Black Friday).
Many of these occasions will generate routine medical emergencies for which care still must be provided. However, history has shown they also can turn into mass-casualty incidents, whether through accidents, acts of terrorism, or other causes. For that reason advance planning is required for any mass gathering or special event.
Planning efforts should include representatives from event medical leadership, security (civilian or private contractor), law enforcement, fire safety, local EMS from the authority having jurisdiction (AHJ), regional or county emergency management, the event incident commander, event sponsors, and other stakeholders. Public safety will have an overall incident commander who will work closely with venue owners and operators and oversee a unified command.
Before any event EMS should conduct a medical needs/hazards assessment. Each event is different, but there are five factors to consider at each: expected weather, expected age of attendees, anticipated drug or alcohol use, location of event, and any potential for violence. All these can result in staffing additional personnel in case a worst-case scenario occurs.
Create an incident action plan (IAP) based on your needs/hazards assessment. Ideally this IAP will include input from all stakeholders to allow every area of concern to be properly managed and all operations information distributed to staff. This document should be provided to all personnel and include unit assignments, incident organization and command structure, a detailed schedule, weather forecast, and the communications plan. You can include detailed assignments for each division, as well as potential MCI plans, weather concerns, and any overall incident objectives.
Both Pennsylvania and New York regulations explicitly state how many ambulances must be at certain-size events.3,4 Requirements can differ; know what your local laws mandate. Requirements listed are typically minimums; you can always (and often should) staff additional units.
Healthcare requirements should be enforced by the permit-issuing agency. If permits are required (some states don’t mandate them), they are typically issued by the local fire marshal’s office or another municipal department. By establishing good relationships with these agencies, EMS can be familiar and perhaps even influence the requirements for the resources they need.
There are four main EMS staffing options for special events. Each has advantages and disadvantages, and some options might not be available in your jurisdiction. Regardless of the staffing method, that entity or agency must be properly licensed to operate at the agreed-upon level by the appropriate governing body.
Local EMS agencies—Local EMS agencies are typically the go-to staffing source for small events, as they already know the area and have infrastructure in place. Larger EMS systems might even have an assigned division or supervisor whose primary role is staffing and managing special events. The primary downside to using the local EMS agency is that smaller systems might not have the manpower or equipment to staff the event.
Local agencies may use dedicated or nondedicated resources to staff mass gatherings. A nondedicated resource is an ambulance from within the 9-1-1 system that’s stationed at the event but can still be utilized for a 9-1-1 call—having them at an event is typically a free courtesy to the event sponsor. A dedicated ambulance is fully equipped and staffed, often by personnel on overtime, but is not part of the 9-1-1 system—it is dedicated solely to the event. For most special events having a dedicated resource is preferred.
Private event EMS agencies/contractors—There are private companies that provide EMS staffing to third-party venues and management and staffing for events. Some 9-1-1 services are also willing to enter into contracts with private partners to provide EMS coverage for special events that is separate from their normal 9-1-1 responsibilities. Smaller events might even ask an EMT to be their “medical person.” However, this may expose the EMT to potential liability. Consider the need for medical direction, provision of equipment, and liability insurance in case of a negative outcome.
Event-managed EMS agencies—Certain venues and venue owners maintain their own EMS systems for events they host. The Carrier Dome Health Squad (at Syracuse University’s Carrier Dome in New York) and NJSEA Emergency Medical Services (at New Jersey Sports Expo Authority’s Meadowlands Sports Complex) are examples of agencies that are 100% funded by their event sponsors or the venue’s owner. The biggest advantage is that the event sponsor has complete control over resources; the drawback is that supplemental/part-time employees often have full-time commitments elsewhere, and their availability may impact how many people you have available. These agencies tend to be more expensive to operate, as the agency must maintain all equipment. They can be ALS or BLS and can include nurses and doctors, depending on how the venue wants to set up its system.
A venue need not select just one staffing method. It can contract with the local EMS service to provide a transporting ambulance (with crew), partner with a private EMS agency to provide bike teams or other specialized resources, and maintain its own internal EMS staffing for foot patrols and overall event management. However, divisions of responsibility should be planned prior to the event, with a clear identification of which group is responsible for which tasks listed in the IAP.
Event-organized response personnel—Some local events will organize their own medical group to provide medical coverage during events. Often this group is composed of volunteer medical personnel (EMTs, paramedics, nurses, doctors, etc.; some even use untrained civilians) who are providing medical care in case an injury occurs. Equipment may be provided by the staff, and members are not credentialed by any regulatory agency, so their prehospital scope is limited to basic first aid only. There is also the question of liability insurance—if a lawsuit arises from a negative outcome, does it get directed to the organization or the individual, and does either party have medical liability insurance? Does the organization have records of the providers' valid credentials? I’ve heard of smaller events asking an EMT (possibly a friend of one of the event planners, or a volunteer who's willing to assist) to be their “medical person." This opens up the EMT to potential personal liability, such as who is their medical director, who is providing the equipment, and other than calling 9-1-1, what are they going to do when they encounter a patient who needs more assistance than they can provide? While this is the cheapest staffing option for the venue, because of the potential risks involved, I don’t recommend it to any organized venue.
There are four basic areas that need coverage during any mass gathering.
Action area—The action area is where the show occurs or the spectators focus their attention. During a sporting event it’s typically the field. During a concert or political rally, it’s a stage. During a marathon it’s the route the runners take, beginning to end. At a fair or carnival, it can be the rides or any area inside the gates through which the general public passes.
The goal of personnel assigned to the action area is to quickly treat and remove any injured person from the area, out of the view of the public, and continue treating them. Venue operators want their paying customers happy and spending money; watching sick or injured people deters that. The goal of these providers is to treat appropriately but interrupt the spectators’ enjoyment of the event as little as possible. They will also interact with other providers and agencies, such as athletic trainers, team physicians, or private security personnel. Familiarity with how you will interact with these other agencies before an incident occurs is crucial to a successful operation.
Spectator locations—These are anywhere spectators are sitting or standing, such as the areas surrounding a football field, areas immediately outside a marathon route, or the concourse/walkway that surrounds the seating area but is still within the venue gates and required ticket areas.
Similar to the action area, incidents in the spectator locations are in public view; they also may present challenges with removing the patient. Think about how you’ll extract a sick patient who’s 25 rows up from the entrance and 30 seats away from the stairs—and then how you’re going to carry that patient down a stairway that was built 40 years ago and not designed for a stair chair. Our goal is to assess and treat any immediate life threats, then remove the patient to a more secure and private area where we can continue assessment and treatment.
Surrounding areas—These include the parking area, tailgating locations, and walkways from these locations to the entrances. This coverage area is typically much larger than the venue itself and less densely populated, making foot patrols unrealistic. We also don’t want to pull resources out of the venue to answer calls here, so having dedicated personnel on either bicycles, carts, or trucks is typically the best option.
Crews can typically assess people in the surrounding area but their resources are limited, at least compared to being inside the venue. Ideally a stable person will be transported from their location to a first aid station; if unstable, transport can be sent directly to their location, and an ambulance can take them to the hospital.
Behind the scenes—Most venues have areas that are not open to the general public but are used by workers who can suffer injuries or illnesses. Examples include a VIP section or luxury boxes, press locations, performers’ dressing rooms, athletes’ locker rooms, service elevators to loading docks, or simple service tunnels. Many venues will restrict routine access, so how to access those behind-the-scenes areas, what the protocol is when interacting with a VIP, and who should be assigned to respond to requests in those areas should all be discussed prior to the day of the event.
Staffing levels can vary depending on the size of the event and risks identified during the hazard assessment. Levels can be as small as a volunteer EMS provider walking around with some basic BLS equipment or as large as a complete EMS system with multiple ALS and BLS ambulances, its own communications coordinator, supervisors, special-operations staff and equipment, and a free-standing emergency room on site.
The accompanying table shows San Francisco EMS’ resource guidelines for mass gatherings.5 The event sponsor provides the mandatory resources as a condition of having a permit issued for the event.
Another consideration is where you can get additional resources if needed. First response and treatment are typically the responsibility of the venue crews; however, if you experience an MCI, you will likely have to request additional transport units from the 9-1-1 system or through an established mutual aid agreement. At what patient count will you declare an MCI? If you have three dedicated transport trucks, would it be prudent to implement your MCI plan and start requesting outside resources after your sixth patient needed transport?
This may lead to staffing additional dedicated ambulances at the scene, to minimize any impact to the local 9-1-1 system. If the local EMS system can’t provide all the ambulances you need without compromising operations, what happens then? Preplan with management and regional emergency management so everyone is aware of what the plan is.
A lot of planning goes into these events, and the bigger they are, the more planning that needs to happen. Use historical data to guide your numbers—for example, if you have six home football games, you can use information from previous games and hazard assessments to guide your planning, making sure to update for any changes.
Staffing for major events is much more involved than simply sending an EMS unit to stand by in case something happens. Proper planning allows for proper resource allocation, which helps minimize any interruption to the local EMS system.
1. De Lorenzo RA. Mass gathering medicine: A review. Prehosp Disaster Med, 1997 Jan–Mar; 12(1): 68–72.
2. World Health Organization. Communicable disease alert and response for mass gatherings, https://www.who.int/csr/mass_gathering/en/.
3. The Pennsylvania Code. Chapter 1033. Special Event EMS, https://www.pacode.com/secure/data/028/chapter1033/chap1033toc.html.
4. New York State, New York Codes, Rules and Regulations. Title: Section 18.4—Emergency health care requirements, https://regs.health.ny.gov/content/section-184-emergency-health-care-requirements.
5. San Francisco Emergency Medical Services Agency. Emergency Medical Services at Mass Gatherings & Special Events, https://sfdem.org/sites/www.emsworld.com/files/FileCenter/Documents/1603-7010%20-%20Mass%20Gathering_05-23-12.pdf.
Sidebar: Dukes vs. Wolfpack: A Case Study In Special Event Response
On Saturday, Sept. 1, 2018, North Carolina State University hosted rival James Madison at Carter-Finley Stadium (seating capacity more than 57,000) for a noon football game in Raleigh, N.C. A high temperature of 91ºF and a humidity in the 70% range resulted in a heat index over 100 degrees.
By the time the crowd had dispersed after the game, medical personnel had seen 177 patients, more than they’d seen during the combined 2016 and 2017 football seasons. Intoxication, heat illness, dehydration, and first-aid emergencies required seamless interaction among multiple agencies.
Dedicated on-site resources were quickly exhausted, necessitating additional transport ambulances from the local 9-1-1 system and resulting in the utilization of all available county EMS units to assist with transporting patients to the ER. Preplanning and having the ability to reassign resources from other roles set the stage for successful management of this event.
Dan Greenhaus, BS, NREMT, has been in public safety for over 20 years, working as an EMS professional, a firefighter and a 9-1-1 dispatcher throughout his career. He worked for several years in the New Brunswick and Newark (NJ) EMS systems before relocating to North Carolina. Dan is currently a firefighter/EMT with the Wake New Hope Fire Department, Raleigh, N.C., and works as an EMS/fire responder at N.C. State University. He also works as an EMS instructor within the N.C. Community College system, regularly teaching EMT initial classes at the college and continuing education courses for fire departments. He is also a senior emergency services instructor at Emergency Services Educators and Consultants. He can be reached at Dan@ESECTraining.com