Introduction
Medical support provided at mass gatherings is beginning to move away from ad hoc delivery of care supported by community 911 resources and toward more organized and structured operations with access to comprehensive medical supplies, equipment, and logistical support. In part, this shift has been driven by the desire for risk mitigation by event organizers. Issues such as disaster preparedness and concern regarding potential terrorist acts also have become important collateral considerations.Reference Arbon1–Reference Rubin and Tanali5 There has been increased concern for maintaining emergency services levels to the community and avoiding event-generated increases in demand that degrade capacity and threaten public safety.Reference Rubin and Tanali5–Reference Thierbach, Wolcke, Peipho, Maybauer and Huth7 Government agencies that grant permits for such events are motivated to avoid event-related drains on public resources. The result has been an increased demand for expertise in the delivery of mass-gathering medicine (MGM) services at sporting and special events and the associated academic interest in this area.
The World Police and Fire Games (WPFG) are held biennially in various countries around the world. The 2009 Games were the largest to date, with 10,599 participants from 55 countries. The Games are open to all non-military and non-private firefighters, police, corrections, border, customs, and immigration officers.8 The vast majority of the competitions were open to the public and free of charge for spectators.
In this descriptive, Canadian study, the complexities of providing medical care at a large-scale, mass-gathering sporting event with international attendance are discussed. Uniquely, this event occurred during a labor dispute between the sole provider of ambulance service in the province, the British Columbia Ambulance Service (BCAS) and the government employer. This situation required significant additional planning and resource allocation in order to minimize the burden on existing emergency services capacity within the public healthcare system and still address the requirements of the WPFG Federation. The Federation required the presence of a standby ambulance at all combat sports as well as those events deemed to be “high risk.” Usually, dedicated standby ambulances and paramedic bike teams are deployed at large mass gatherings through the BCAS Special Operations unit. This unit was inactive during the labor dispute, and BCAS provided only “core services” to the public at large. As such, no extra resources were available for the duration of the games, and the Games' medical team had to fill this role.
This study addresses the following research question: What injuries and illnesses occurred for all attendees and participants presenting to the medical team during the 2009 WPFG? For consistency with the published MGM literature, specific information regarding the following questions was sought:
1. What was the composition of the medical team and response capability?
2. What was the patient presentation rate (PPR)?
3. What was the case mix, including the nature of the more serious cases?
4. What was the ambulance transfer rate (ATR)?
5 What was the overall medical transfer rate (MTR) and the transfer to hospital rate? and
6. In terms of the local healthcare system, what was the impact of the WPFG?
Literature Review
Mass gatherings are an important part of all communities, and include social, cultural, political and sporting events. Such events have predictable needs for increased security, policing, traffic management, sanitation and food services.Reference Hodgetts and Cooke9 In contrast, there is a lack of consensus that these events require dedicated and specialized medical services.Reference Arbon1,Reference Milsten, Maguire, Billell and Seaman4,Reference Arbon, Bridgewater and Smith10–Reference Zeitz, Zeitz and Kadow-Griffen16 Furthermore, although the literature describes the medical response for numerous mass gathering events, few report on such events in a Canadian context.
Currently, the body of literature with regard to the provision of medical support for mass gatherings is under developed. There is no consensus on the definition of a mass gathering. A recent definition of a mass gathering describes a “situation or event during which crowds gather and where there is the potential for a delayed response to emergencies because of access or other features of the environment and location”.Reference Arbon1,Reference Milsten, Maguire, Billell and Seaman4,Reference Arbon, Bridgewater and Smith10,Reference Arbon17 The authors favor this definition, as it recognizes that the planning for and the delivery of health services during mass gatherings is complicated by unique features of the event and its attendees as well as the broader context of health service provision.
Past literature has contributed to the understanding of individual events and has identified significant variables that may influence PPR and case mix. However, most of the work is limited to retrospective descriptive data and accounts of single events or event types.Reference Arbon1,Reference Zeitz, Schneider, Jarrett and Zeitz18 No externally validated evidence-based guidelines or prediction rules exist to aid event producers, medical directors, or government permit granting agencies in determining requirements.Reference Arbon, Bridgewater and Smith10,Reference Zeitz, Bolton, Dippy, Dowling, Francis, Thorne, Butler and Zeitz15 As such, events have been conducted with diverse response teams, varying from basic first aid provided by security or volunteer first aid organizations to complex multi-disciplinary medical teams with critical care capabilities.
Planning for mass gathering events includes predicting the number and composition of medical staff required to provide the intended level of service on site. Teams described in the literature are heterogeneous and include individuals from a wide variety of healthcare backgrounds.Reference Grange, Baumann and Vaezazizi6,,Reference Ouanian, Salinas, Shear and Rodney19–Reference Feldman, Lukins, Verbeek, Burgess and Schwartz20 Retrospective studies have attempted to demonstrate the effect of the medical team on the MTR; however, no formal recommendations exist, and current evidence lacks methodological rigor.Reference Grange, Baumann and Vaezazizi6 For example, Grange et al concluded that on-site physicians reduced ambulance transports by 89%.Reference Grange, Baumann and Vaezazizi6 However, this retrospective study, was largely opinion-based. Similarly, the authors of a case summary published in 1982 in Annals of Emergency Medicine recommended the staffing of one physician per 12,500 attendees, one registered nurse per 10,000 attendees, and one paramedic per 2,600 attendees based on consensus opinion.Reference Ouanian, Salinas, Shear and Rodney19
Part of the challenge in planning the composition of an event medical team and systems stems from the lack of detailed understanding of the impact of the various factors affecting the PPR at a given event, despite numerous retrospective and descriptive studies.Reference Enock and Jocobs21 Literature reviews have identified both environmental and population factors including heat index, event duration, type of event, attendance, profile of attendees, mobile or seated audience, outdoor or indoor and the presence and availability of alcohol and/or recreational drugs.Reference Arbon1,Reference Milsten, Maguire, Billell and Seaman4,Reference Enock and Jocobs21 These acknowledged risk factors have yet to be prospectively validated and weighted in terms of the impact of each factor on the overall PPR. This gap in the literature manifests as a lack of practice guidelines upon which to base recommendations regarding equipment, medication, supplies, and medical team composition for MGM events.
Methods
Data Collection
Every patient encounter at any medical facility or asset at the 2009 WPFG was prospectively documented. Data were captured on a standardized medical encounter form that provided detailed information about the illness or injury using a combination of narrative space and tick boxes. A version of this form had been piloted and used at several prior events. For continuous quality improvement purposes, data were abstracted to an Excel (Microsoft, Redmond, WA) spreadsheet within 12 hours of each encounter by a group of para-medical and lay volunteers who were instructed on extracting the medical data and blinded to the purpose of the data collection. The resulting summative database was used for this manuscript and supported by a manual review of the original documents where required.
Results
Context of the Event
In total, 64 sporting events were staged over a 10-day period. Events were spread over 327 km in urban and suburban areas with a population base in excess of 2.27 million people in southwestern British Columbia.22 Both indoor and outdoor venues were in use. The mean temperature was 29–34 degrees Celsius throughout the 10-day event with a daily maximum humidex ranging 23–28.27 The sun was shining each day. The crowd was mobile and the crowd density was variable but rarely excessive. Alcohol was available on-site at multiple venues.
Description of the Medical Team
Initially, all medical staff members were recruited on a volunteer basis and a nominal honorarium was later offered in order to attract enough appropriately skilled providers. The medical team was comprised of 270 individuals from a wide variety of health professions (Table 1). Volunteers were required to attend a two-hour orientation session and were provided with a comprehensive medical team manual detailing the policies and procedures for the Games.
Table 1 Medical team members
Organization of Services
The objective of the medical team was to assess and treat individuals presenting for care so that they could safely return to competition. An additional goal for those who were unable to return to competition or requiring advanced service or diagnostic imaging was to provide the required care without significantly impacting already overcrowded local emergency departments. Additional capacity and resources were marshaled to account for significantly delayed emergency responses or emergency transports by ambulance, due to the ongoing labor dispute. If a particular injury required care or service that could not be provided on site (e.g., diagnostic imaging or specialty referral), a transfer via a medical team vehicle was undertaken. An overview of medical organization is presented in Figure 1.
Figure 1. Medical organizational structure
Team members were deployed to two polyclinics, up to four regional roving response vehicles, or medical stations adjacent to the fields of play. Medical staff at the polyclinics provided urgent and non-urgent medical care for participants, volunteers, and staff. Traditional Chinese Medicine and acupuncture, chiropractic, massage, physiotherapy services and sports taping were also made available to athletes. An on-call dentist was available and utilized.
The Main Medical Clinic was situated in a geographically central area where several major events were scheduled, including most of the contact and combat sports (such as boxing and martial arts), the entertainment village (the main beer garden) and volunteer headquarters. The Main Medical Clinic had 13 beds and five treatment chairs. This clinic was better equipped than many at mass gatherings such as football or baseball games and was more in line with events such as the Olympic Games and included a wide range of medical supplies including advanced airway and advanced life support (ALS) equipment. Suture supplies and casting material were available as well as Cryo-Tubs© for immersion therapies. The other clinic was located at the administrative hub of the Games and consisted of five treatment beds with primarily advanced first aid equipment and a massage therapy service.
Roving teams equipped with ALS equipment and spine boards were deployed regionally in support of the busiest activity hubs on a given day. The team traveled in minivans that were dispatched by a dedicated medical dispatcher who received all calls for medical assistance from members of the medical team, as well as any other Games staff, via a dedicated telephone line. Calls were also referred from the general Games information line, via cellular telephone, radio, or text message. A team of two responders, usually emergency medical responders, or a combination of registered nurse and a skilled first-aid provider, would respond to dispatch requests for medical assistance. The objective of the roving response teams was to provide a higher level of care than was available from the onsite medical teams, to stabilize patients, and to provide life-preserving care, in the event that 9-1-1 response was delayed due to service disruptions. Medical emergencies were triaged through our Games medical dispatch, which would activate the 9-1-1 system when necessary and coordinate bystander calls with 9-1-1 dispatch.
Assignment of resources on the field of play was based on several considerations including proximity to a trauma referral center, the WPFG Federation specific requirements with regard to medical support, a review of the healthcare literature, and the perceived level of risk for specific events. For example, a physician was onsite for all combat sports. On site medical personnel covered 46 different sporting competitions (76% of WPFG events). The low risk events that did not have dedicated medical team members were covered by the regional roving response teams and were provided with first aid kits and standing medical protocols for first aid and for obtaining assistance when required.
Patient Encounters
There were 1,462 patient encounters documented over a period of 10 days (Figure 2) for a mean of 146 daily visits. The PPR was 109.4/1,000 (1,462/13,363 of attendees required medical attention). Competitors accounted for the majority of visits. Patient encounters were separated into “major” and “minor” categories. Major encounters were those patients who required multiple reassessments, transfer to an emergency room for assessment, serious fractures requiring potential operative reduction, and/or those with potentially life threatening conditions or injuries. All other encounters were classified as minor. Encounters were further categorized according to the body system impacted by the presenting complaint as detailed in Figure 3. There were no deaths. As anticipated, most of the patients were assessed and treated for musculoskeletal injuries (53.8%).
Figure 2. Number of patient encounters by date
Figure 3. Patient encounters by body system
Injuries and illnesses were addressed on site whenever possible. However, transport off site for additional care or diagnostics was sometimes required. A total of 31 individuals were sent off site for diagnostics or treatment. Fourteen individuals were sent to local radiology clinics and four others were sent to a community dentist; 13 went to an emergency room and these referrals were predominantly made after hours when community-based resources were not available. These transfers did not require public ambulance services. The ATR for the 2009 WPFG was 0.52/1,000 with seven emergency ambulance responses and transfers (9-1-1 calls) during the 10-day event. The 9-1-1 cases involved the following: heat exhaustion, concussive symptoms (n = 2), collapse, cervical spine injury (n = 2), and a severe ankle injury. The overall MTR (all off-site referrals including ambulance transfers) was 2.32/1,000.
For some patient encounters (n = 78), the presence of physicians (and one nurse practitioner) allowed the medical team to provide definitive care, averting a visit to a local emergency room or walk-in clinic. Examples of such definitive care include the application of multiple plaster and fiberglass splints, reduction of two shoulder dislocations, an incision and drainage of an abscess, management of a severe allergic reaction, and several complex laceration repairs. In addition, non-emergent transfers for diagnostics such as x-rays were provided by medical team members to avoid burdening local emergency services.
Discussion
Medical surveillance for mass-gathering sporting events is reported infrequently in the healthcare literature. However, two reports help situate the findings of this study in the larger body of literature. During the 2001 WPFG, 9,038 athletes participated in 59 sporting events over the course of seven days. A PPR of 392/1,000 athletes and a MTR of 2.4/1,000 athletes was reported; 22 patients were sent to hospital.Reference Sloan, Somerville, Olinger, Billows and Brokaw23 As with the present study, the majority of injuries were musculoskeletal.
For the 2009 Games, the PPR was substantially lower at 109.4/1,000 and the MTR was similar at 2.32/1,000. The lower PPR may be related to the large number of massage therapists, chiropractors, and other therapists and trainers who provided unlimited treatment and taping to competitors, free of charge. Additionally, many athletes sought treatment both prior to competition and after in preparation for their next event. As reported in Figure 3, 27.7% of patient encounters were for prevention (e.g., massage, taping, acupuncture, etc). A prospective study with regard to prevention during mass participation sporting events may be of interest in the future. The similar MTR reported in the present study is also of interest because the 2001 medical team had access to an x-ray machine and preformed 120 radiographic examinations, averting the need to transfer off-site for imaging.
In contrast to the above reports, the Central American and Caribbean Games of 1993, in which 4400 athletes competed in 28 sporting eventsReference Perdomo, Rivera, Becerra, Rodriguez, Frontera and Martin24 describes a medical program in which patients were assessed and treated in a hospital setting. The PPR was 180.5/1,000 athletes with the majority of visits for the treatment of musculoskeletal complaints (38%) and respiratory illness (23%). The higher PPR reported in that study may be explained by the climate; higher temperature and humidity may have triggered heat-related illness. Given that the medical care offered in 1993 was hospital-based rather than on site, PPRs possibly may have differed due to financial considerations preventing attendance for care as well as a possible perception that a hospital visit involves a more serious injury than a visit to an event-affiliated clinic, as in the 2001 WPFG.
Mass participation events, or Category 3 mass gatherings, where participant numbers exceed spectators,Reference Hodgetts and Cooke9,Reference Saunders, Criss, Steckl, Meislin, Raife and Allen13 have PPR's that are higher than those reported for other mass gatherings that involve primarily spectators. In the current study, 10.9% of attendees presented for assessment. In Europe and Australia, it has been observed that approximately 0.1% of attendees at a mass gathering event can be expected to present for treatment.Reference Saunders, Criss, Steckl, Meislin, Raife and Allen13 For example, at a children's festival in Germany with 100,000 attendees only 0.2% presented for treatment.Reference Thierbach, Wolcke, Peipho, Maybauer and Huth7 Attendees at a rock festival with 62,000 attendees presented at a rate of 1.7%.Reference Hewitt, Jarrett and Winter11 In a large series of mass gathering with an attendance of 12,046,436 people in the Australian context, on average 0.1% of attendees presented for treatment.Reference Arbon, Bridgewater and Smith10 In a retrospective analysis regarding medical support for the annual Australian Royal Horticultural Show over a period of seven years, the authors reported an average PPR of 1.7%.Reference Zeitz, Schneider, Jarrett and Zeitz18
An overview of the literature with regard to this topic reveals that particular injury and illness patterns prevail depending on the nature of the mass gathering. For example, rock concert attendees often present with traumatic injuries resulting from crowd motion, thrown objects, or multi-factorial syncope.Reference Hewitt, Jarrett and Winter11 At marathons, dermatologic complaints predominate including blisters and chaffing. The present event was somewhat unique in that sporting events of both “winter and summer” variety took place concurrently. Musculoskeletal and traumatic injuries predominated in the sports where they were expected to do so, including soccer, hockey, and flag football. Consideration of the expected injury patterns or the constellation of presenting complaints is an invaluable source of information in making determinations with regard to staffing and equipment needs for MGM events.
The literature confirms the challenges associated with determining the optimum number of physicians and other healthcare professionals for particular events. Widely variable reports about medical teams for mass gatherings were found.Reference Ouanian, Salinas, Shear and Rodney19 For example, at a rock festival with 62,000 attendees, 12 physicians were on site for a ratio of 5166:1. In contrast, for the 2001 WPFG there were 22 physicians available over the course of seven days for a ratio of 411:1. In the present study there were a total of 18 physicians available in a varied deployment over the course of 10 days of competition for a ratio of 589:1.
The involvement of physicians with an emergency medicine background and the effect on hospital transfer rates has not been definitively studied. In the present study, the presence of emergency room physicians allowed the medical team to avert hospital visits as previously discussed. Low hospital referral rates are discussed in the literature, underlining the importance of medical support of mass gatherings.Reference Hodgetts and Cooke9,Reference Zeitz, Schneider, Jarrett and Zeitz18,Reference Hnatow and Gordon25 At the 2009 WPFG, the rate of hospital, whether for radiology or treatment, was 0.23% and would have been lower if the polyclinic staff had access to x-ray technology and staff.
In general, the science of mass gathering medicine is under-developed. Summaries published by organizations such as the American College of Emergency Physicians26 and the North American Emergency Medical Services Physicians' Association27 are consensus-based and lack prospective evidence. Validated, evidence-based recommendations for the medical staffing needs of mass gathering events would contribute to more standardized and optimized medical care. Mass gathering medicine, a unique form of prehospital emergency care, should be recognized as a discrete body of knowledge and studied in a more rigorous fashion. Specifically, a central registry, including a triage system/acuity index, would strengthen the ability to plan appropriately for mass gathering events, reducing the burden on local, over-taxed emergency services. Monitoring the usage rates of the local emergency rooms would provide valuable information about local community burden for future events.
Limitations
The present study has four main limitations. First, caution is required when interpreting the statistics presented in this manuscript. The 2009 WPFG were open to the public and spectators were not tracked. Accordingly, there was no way to determine the total number of attendees. The data above were analyzed using a proxy denominator (the number of registered athletes plus the number of volunteers and the number of administrators). This figure does not include the spectators and is therefore an artificially low number. The PPR, TTHR, and ATR are undoubtedly inflated when all persons at risk of presenting for care are considered.
Although every effort was made to ensure compliance with documentation, the widely disseminated nature of this event made it impossible to confirm that every encounter was captured and that every completed medical encounter form was collected and recorded. Since the primary data capture was performed in a clinical context without any additional infrastructure employed specifically to generate these data, in some cases, encounter forms were incomplete. For example, for 72 encounter forms no date of treatment was specified; it was possible to ascertain the date based on the event schedule and treating provider in some cases, but in others this information was not discernable. Similarly, due to missing data, it is impossible to reliably report on the demographic data of those injured. Also, the results were not able to be analyzed retrospectively to identify specific injury incidence related to high risk versus low risk sporting events. Finally, the ratio of athletes to spectators or volunteers/staff presenting for treatment were not reliably determined, although anecdotally, only a small number of volunteers and staff sought care. Although all Games affiliated persons were encouraged to seek medical care from the Games Medical Team, local emergency rooms and the ambulance service were not polled to determine if Games affiliated persons sought care directly. As such, the total impact of the Games on local healthcare services cannot be commented on definitively.
The lack of consensus within mass-gathering literature regarding an acuity scale or a tool for measuring the complexity of the case mix created challenges. Researchers involved in future events should reflect upon these challenges and strive to improve the literature in this regard.
Conclusions
In general, reports about mass gatherings have tended to be anecdotal and/or descriptive in nature; thus, theory development has been slow.Reference Arbon17 More recently however, international attention for this topic has increased. Events that bring together large numbers of individuals (e.g., sporting events, aid concerts) are a constant in community life and the providers of public emergency services are moving to reduce the burden on existing limited resources and capacity. Additionally, concerns relating to the risk of terrorist acts or disasters associated with mass gathering events have focused attention on safety and security for those attending or participating in mass gatherings.Reference Arbon1–Reference Rubin and Tanali5 The 2009 World Police and Fire Games represent a mass gathering and an international competition between police, fire fighters, and corrections officers. With 64 sporting events, the Games presented a challenge for the medical team in terms of determining an adequate mix and number for the medical team as well as deployment of these staff and the resources required. Limited information was available in the literature and no information was available from past Games to guide planning. Additionally, an inability to have contracted ambulances on standby at events, coupled with a reduced response capacity by the sole provider of ambulance services in the province necessitated the development of a contingency plan that utilized medical team members in regional response vehicles. Despite these challenges, with advanced planning, athletes, spectators, and volunteers at the World Games were provided with on-site, timely, and effective medical care in a Canadian context.
Abbreviations:
ALS = advanced life support
ATR = ambulance transfer rate
BCAS = British Columbia Ambulance Service
MGM = mass gathering medicine
MTR = medical transfer rate
PPR = patient presentation rate
WPFG = World Police and Fire Games
