We explore the health care literature and draw on two decades of experience in the provision of medical care at mass gatherings and special events to illustrate the complementary aspects of mass gathering medical support and disaster medicine. Most communities have occasions during which large numbers of people assemble in public or private spaces for the purpose of celebrating or participating in musical, sporting, cultural, religious, political, and other events. Collectively, these events are referred to as mass gatherings. The planning, preparation, and delivery of health-related services at mass gatherings are understood to be within the discipline of emergency medicine. As well, we note that owing to international events in recent years, there has been a heightened awareness of and interest in disaster medicine and the level of community preparedness for disasters. We propose that a synergy exists between mass gathering medicine and disaster medicine.

Literature review and comparative analysis.

Many aspects of the provision of medical support for mass gathering events overlap with the skill set and expertise required to plan and implement a successful medical response to a natural disaster, terrorist incident, or other form of disaster.

There are several practical opportunities to link the two fields in a proactive manner. These opportunities should be pursued as a way to improve the level of disaster preparedness at the municipal, provincial, and national levels.

Unpredictable environmental conditions, crowd dynamics, and a variety of medical emergencies create logistical and clinical obstacles when planning emergency medical response coverage for mass-gathering events. In a collaborative endeavor between a university athletics program and an academic division of Emergency Medicine, a stadium emergency medical response system was created consisting of hospital-based healthcare providers and pre-hospital healthcare providers.

Provide descriptive statistics relevant to the nature and frequency of injury/illness, location of treatment within stadium confines, and resources used in the care of students, event staff, and spectators during collegiate football operations, to assist in future planning of mass-gathering events.

A continuously updated, quality assurance database of de-identified, aggregate statistics was utilized to analyze trends regarding aspects of medical operations.

During a 7-game home football season, there were a total of 399 patients encounters, including 1 cardiac arrest (0.25%), 12 “life-threatening” (3.01%), 121 urgent (30.33%), and 266 routine (66.67%). Total season attendance was 201,248 attendees (28,749/game and 19.83 patients encounters per 10,000 in attendance). Twenty-eight patients were transported (1.39 per 10,000), with eight resultant hospital admissions. Encounters varied by complaint, with skin (42%) comprising the largest number of encounters. Other categories included: (1) heat-related (23.5%); (2) allergic (15%); (3) neurologic (10.3%); (4) cardiopulmonary (3.5%); (5) gastrointestinal (3.6%); (6) musculoskeletal (5%); and (7) other (5%). Encounters increased noticeably when the heat index was greater than 80 °F– (29.4 vs. 10.5 per 10,000 attendees).

The collaborative effort by a multi-level provider model adequately covered presenting medical conditions. Consistent with previously literature, a strong correlation existed between heat index and number of patient encounters deemed urgent and routine. Interestingly, the number of “life-threatening” encounters did not appear to vary much with the heat index. Further studies of medical presentations and provider/resource utilization could provide for predictive modeling of future staffing and supply models.

Workforce planning for first aid and medical coverage of mass gatherings is hampered by limited research. In particular, the characteristics and likely presentation patterns of low-volume mass gatherings of between several hundred to several thousand people are poorly described in the existing literature.

This study was conducted to:

1. Describe key patient and event characteristics of medical presentations at a series of mass gatherings, including events smaller than those previously described in the literature;

2. Determine whether event type and event size affect the mean number of patients presenting for treatment per event, and specifically, whether the 1:2,000 deployment rule used by St John Ambulance Australia is appropriate; and

3. Identify factors that are predictive of injury at mass gatherings.

A retrospective, observational, case-series design was used to examine all cases treated by two Divisions of St John Ambulance (Queensland) in the greater metropolitan Brisbane region over a three-year period (01 January 2002–31 December 2004). Data were obtained from routinely collected patient treatment forms completed by St John officers at the time of treatment. Event-related data (e.g., weather, event size) were obtained from event forms designed for this study. Outcome measures include: total and average number of patient presentations for each event; event type; and event size category. Descriptive analyses were conducted using chi-square tests, and mean presentations per event and event type were investigated using Kruskal-Wallis tests. Logistic regression analyses were used to identify variables independently associated with injury presentation (compared with non-injury presentations).

Over the three-year study period, St John Ambulance officers treated 705 patients over 156 separate events. The mean number of patients who presented with any medical condition at small events (≤2,000 attendees) did not differ significantly from that of large (>2,000 attendees) events (4.44 vs. 4.67, F = 0.72, df = 1, 154, p = 0.79). Logistic regression analyses indicated that presentation with an injury compared with non-injury was independently associated with male gender, winter season, and sporting events, even after adjusting for relevant variables.

In this study of low-volume mass gatherings, a similar number of patients sought medical treatment at small (<2,000 patrons) and large (>2,000 patrons) events. This demonstrates that for low-volume mass gatherings, planning based solely on anticipated event size may be flawed, and could lead to inappropriate levels of first-aid coverage. This study also highlights the importance of considering other factors, such as event type and patient characteristics, when determining appropriate first-aid resourcing for low-volume events. Additionally, identification of factors predictive of injury presentations at mass gatherings has the potential to significantly enhance the ability of event coordinators to plan effective prevention strategies and response capability for these events.

Past history of mass casualties related to international football games brought the importance of practical planning, preparedness, simulation training, and analysis of potential patient presentations to the forefront of emergency research.

The Japanese Ministry of Health, Labor, and Welfare established the Health Research Team (HRT-MHLW) for the 2002 FIFA World Cup game (FIFAWC). The HRT-MHLW collected patient data related to the games and analyzed the related factors regarding patient presentations.

A total of 1,661 patients presented for evaluation and care from all 32 games in Japan. The patient presentation rate per 1,000 spectators per game was 1.21 and the transport-to-hospital rate was 0.05. The step-wise regression analysis identified that the patient presentations rate increased where access was difficult. As the number of total spectators increased, the patient presentation rate decreased. (p <0.0001, r = 0.823, r2 = 0.677).

In order to develop mass-gathering medical-care plans in accordance with the types and sizes of mass gatherings, it is necessary to collect data and examine risk factors for patient presentations for a variety of events.

St John Ambulance Operations Branch Volunteers have been providing first-aid services at the Royal Adelaide Show for 90 years. The project arose from a need to more accurately predict the workload for first-aid providers at mass gathering events. A formal analysis of workload patterns and the determinants of workload had not been performed.

Casualty presentation workload would be predicted by factors including day of the week, weather, and crowd size.

Collated and analyzed casualty reports over a seven-year period representing >7,000 patients who presented for first-aid assistance for that period (63 show days) were reviewed retrospectively.

Casualty presentations correlated significantly with crowd size, maximum daily temperature, humidity, and day of the week. Patient presentation rate had heterogeneous determinants. The most frequent presentation was minor medical problems with Wednesdays attracting higher casualty presentations and more major medical categories.

Individual event analysis is a useful mechanism to assist in determining resource allocation at mass gathering events providing an evidence base upon which to make decisions about future needs. Subsequent analysis of other events will assist in supporting accurate predictor models.

This paper reports on research into the influence of environmental factors (including crowd size, temperature, humidity, and venue type) on the number of patients and the patient problems presenting to firstaid services at large, public events in Australia. Regression models were developed to predict rates of patient presentation and of transportation-to-a-hospital for future mass gatherings.

To develop a data set and predictive model that can be applied across venues and types of mass gathering events that is not venue or event specific. Data collected will allow informed event planning for future mass gatherings for which health care services are required.

Mass gatherings were defined as public events attended by in excess of 25,000 people. Over a period of 12 months, 201 mass gatherings attended by a combined audience in excess of 12 million people were surveyed through-out Australia. The survey was undertaken by St. John Ambulance Australia personnel. The researchers collected data on the incidence and type of patients presenting for treatment and on the environmental factors that may influence these presentations. A standard reporting format and definition of event geography was employed to overcome the event-specific nature of many previous surveys.

There are 11,956 patients in the sample. The patient presentation rate across all event types was 0.992/1,000 attendees, and the transportation-to-hospital rate was 0.027/1,000 persons in attendance. The rates of patient presentations declined slightly as crowd sizes increased. The weather (particularly the relative humidity) was related positively to an increase in the rates of presentations. Other factors that influenced the number and type of patients presenting were the mobility of the crowd, the availability of alcohol, the event being enclosed by a boundary, and the number of patient-care personnel on duty.

Three regression models were developed to predict presentation rates at future events.

Several features of the event environment influence patient presentation rates, and that the prediction of patient load at these events is complex and multifactorial. The use of regression modeling and close attention to existing historical data for an event can improve planning and the provision of health care services at mass gatherings.