Introduction
Although mass assemblages are defined as 1,000 or more persons in an area, in accordance with some information in literature, they are also defined as a crowd larger than 25,000 persons. The comprehensiveness of the definition expresses a large mass of humans who participated in an event that took place at a limited time in a private sphere.Reference Memish, Stephens, Steffen and Ahmed 1 , Reference Arbon, Bridgewater and Smith 2 Health risks during these organizations include outbreaks of infectious diseases, non-communicable diseases, environmental influences (such as problems and confluences related to thermal comfort), trauma, and terrorist attacks. 3 Predictions regarding use of medical sources in these events depend on some variables. These variables include the weather conditions, the duration of the event, consist inside or outdoors of the event, the status of audience sitting or standing, risk profiles of participants, use of alcohol and medications, crowd density, type and characteristics of the event, and geography of the place.Reference Arbon, Bridgewater and Smith 2 , 3
The importance of mass assemblages appears during national and international security, crowd management, emergency preparedness, environmental health, travel medicine, vaccination, surveillance of communicable disease, and presentation of emergency medical care services.Reference Chang, Chang, Huang, Huang, Chien and Tsai 4 The mass assemblage medical service includes provision of medical care to patients or injured persons, such as rapid access, triage, stabilization, and transport on the scene. This case is realized by the superior abilities of the Emergency Medical Services (EMS), which provide routine emergency services.Reference Biddinger, Baggish and Harrington 5
In this work of mass assemblage, it was conducted for the purpose of evaluating the two-day EMS medical records carried out within the 100th anniversary commemoration ceremonies of the Gallipoli Wars (Çanakkale Amphibious Wars – Turkey). The study is an important provision of the effective allocation of resources and in terms of planning mass medical care responses at similar events in the next years.
Method
In this descriptive study, medical registration forms of Çanakkale (Turkey) EMS were evaluated, which were held within the scope of the 100th anniversary of the Gallipoli Wars in the hours of 10:00am on April 24, 2015 through 4:00pm on April 25, 2015. For research, necessary permission had been obtained from Çanakkale Onsekiz Mart University (Çanakkale, Turkey) and ethical approval from the Clinical Research Ethics Committee and Çanakkale Provincial Directorate of Health (Çanakkale, Turkey). The medical record forms were stored both in a computer environment and in a central location. The forms were obtained from these two media. These include the sociodemographic characteristics of the patient, the station, the time, the social insurance, the call type, the call origin, the scene, the first examination findings, the Glasgow Coma Scale, the pre-diagnosis, and the hospital where the transfer was made. 6 Alcohol and illegal drug use are prohibited at the ceremonies. A total of 221 patients/injured registrations were reached within the ceremonies in two days. The classifications of the records were not based on a disease classification. The data obtained from medical forms and reports from the ceremonies were yielded descriptive statistics by transferring to SPSS 19.0 statistical package program (IBM; Armonk, New York USA). Furthermore, the patient presentation rate (PPR) was obtained by dividing the number of patients/injured persons admitted to the medical services into the number of total participants and multiplying the resulting number by 1,000; the transport to hospital rate (TTHR) was calculated by dividing the number of patients transferred from the region to the closest hospital into the number of participants overall and multiplying the resulting number by 1,000;Reference Arbon, Bridgewater and Smith 2 , Reference Ho, Koenig and Quek 7 and the pre-diagnosis rate (PDR) was calculated by dividing the number of certain pre-diagnosis of patients/injured persons into the number of participants overall and multiplying the resulting number by 1,000.Reference Ahmed, Arabi and Memish 8
Findings
Variables Related to the Activity
Resume of Mass Gathering—One hundred years ago, in 1915, the Gallipoli Wars, which extended the First World War because of its results and was known as the “Gentlemen’s War,” broke out. The battle is also known as “Anzac Day” on the historic stage. Today, the children of the nations involved in this war attend the commemoration ceremonies, which are held annually. This year, on the occasion of the 100th anniversary of the Battle of Gallipoli in Çanakkale, a large number of people from all of the nations who sent troops to the battle were present at the ceremonies. In the commemoration ceremonies, during two days, ceremonies and walks were held in various places. Figure 1 shows the distribution of mobile operating rooms (MORs) and ambulances in the area.
Figure 1 The Area Map. Abbreviation: MOR, mobile operating room.
Features of the Peninsula
The events organized as a part of the commemoration ceremonies were held in a large Historical National Park (HNP) of 33,500 hectares. The region of HNP consists of an extensive mountainous terrain and roughly resembles a triangle.
Participants’ Country Profiles, Estimated Numbers, Temperature, and Weather Conditions
The commemoration activities lasted two days in for day and night, on April 24-25, 2015, and according to the estimations of the official institutions, 50,000 people attended the ceremonies: 24,000 scouts between the age of 10-25 years; 1,000 volunteers of Turkish Red Crescent (Ankara, Turkey); 10,500 people from Australia and New Zealand (2,000 of them were disabled and elderly); and approximately 15,000 people consisting of health, safety officers, fire fighters, and other ceremonial officers, as well as the limited participation of local people who were present at the ceremonies, which lasted for 48 hours throughout the peninsula. However, the estimated demographic information for the total population participating in the event was not reached (standard deviation and sex and age).
The first day of the ceremonies, the weather was clear and partly cloudy, the temperature was between 4°C - 16°C; and the second day, temperature was between 9°C - 17°C.
Mobile Operating Rooms, Mobile Command
A MOR is a part of the mobile hospital systems providing emergency medical assistance in a short time in the affected areas in case of emergencies, such as disasters and wars, or when health facilities are inactive for some reason. Accordingly, each MOR in the region provided the services of triage, emergency patient care, and patient transfer.
Four MORs located in four different places (Abide, Anzac Cove, Chunuk Bair, and Kocadere) of the HNP region performed service. The EMS system was located in the MOR and ceremonial areas during the event. The ambulances in the MOR transferred the patients/injured persons to the relevant transfer vehicles (helicopters or sea ambulances) or directly to hospitals in line with the directives of mobile and central commands. Transfer operations and the applications of patients/injured persons who came to the MOR or other health teams were registered by the teams and the data were transferred to mobile command centers. Mobile command centers were situated in the most appropriate locations in HNP region in terms of wireless communication with health teams. Furthermore, the communication between mobile command and health teams was carried out via phone and text messaging.
Variables Related to the Patients
There were 221 cases in which EMS intervened within the scope of the activities; 193 (87.3%) of the cases applied to MORs stationed in the ceremony area while 28 (12.7%) of them applied directly to the health care team stationed in a large place in the ceremony area. A total of 29 (13.1%) of the cases were transferred to the hospital for further evaluation and treatment; 25 (86.2%) of the medical transports were transferred via sea ambulances and four (13.8%) of them were transferred by air ambulances. The PPR of the patients who were treated during the two days was 4.42, and the TTHR of the cases transferred to the hospital was calculated as 0.58.
The records of 139 (72.0%) of the cases, which were intervened by EMS in MOR during the ceremonies, were accessible. Consultancy services provided were not recorded. Overall, 96 (69.1%) of the cases belonged to Turkish citizens while 30 (21.6%) of the cases belonged to Australian citizens. Further, there were also five Azerbaijani, five New Zealander, one Bulgarian, one Senegalese, and one Kosovan among the cases intervened. The mean (SD) age of the cases was 29.53 (16.02) years; 35 (28.2%) of them were in the age range of 20-24 years; 78 (56.1%) of them were male. Moreover, 90 (64.7%) of them applied to the Kocadere MOR and 42 (30.2%) of them had private health insurance (Table 1).
Table 1 The Distribution of Cases Based on Certain Demographic Characteristics (Çanakkale – Turkey, 2015)
Abbreviation: MOR, mobile operating room.
Between the pre-diagnosis distributions of cases intervened by EMS in the MOR in the scope of the activities, trauma with 20 (14.5%), headache with 19 (13.8%), and acute gastroenteritis with 13 (9.4%) were respectively the first three diagnoses (Table 2).
Table 2 The Distribution of Cases Based on Injuries and Diseases (Çanakkale – Turkey, 2015)
Discussion
In general, mass gatherings have an important impact on the regional capacity of EMS. This impact derives from the inadequacy of EMS to meet the excessive health service demands. This demand causes an overload on the operations of the health care system, available equipment, and personnel. For this reason, four MORs were established in the region of the HNP within the scope of the commemoration ceremonies. In this way, the potentially excessive volumes of patients who may apply to the emergency services were prevented.
When the relevant literature on mass gatherings was analyzed, it appeared that the studies on the organizations such as sports, concerts, and pilgrimages were abundant. Specially, it is known that alcohol and various drugs are used at concerts, and deaths due to overdose occur as well.Reference Lund and Turris 9 In this study, there was no evidence of illness or injury related to the use of alcohol or drugs, as in other mass gatherings, due to the prohibition of alcohol and illegal drug use during the ceremonies.
Similar to this study, in the literature, it was concluded that there were complaints related to the musculoskeletal system in certain mass gatherings.Reference Milsten, Seaman, Liu, Bissell and Maguire 10 It may result from the rugged structure of the region of the HNP, the existence of pathways, the presence of elderly and disabled people with potentially weaker musculoskeletal systems compared to other age groups among the participants, the features of the shoes that they wore (such as slippers and high heels), the exhaustion of most of the participants due to a long journey on the sea, and the ceremonies which lasted for two days.
One of the most common pre-diagnosis of the participants was gastroenteritis (n=13; 9.4%; the PDR of 0.36). In 1986, the incidence rate for gastroenteritis cases during a pilgrimage was calculated as 0.44 per 1,000; and in a study among race volunteers in 2002, it was found that gastroenteritis cases ranked third, followed by cardiovascular and respiratory system diseases.Reference Ahmed, Arabi and Memish 8 Food hygiene may be one of the greatest problems in the places where artificial populations gather, such as ceremonies. The issues that may occur in regard to food hygiene: epidemics might bring about.Reference Ahmed, Arabi and Memish 8
In this study, the PPR was calculated as 4.4 and the TTHR was calculated as 0.58. In a study performed in Singapore Formula One Races, the PPR was calculated as 2.17 and the TTHR was calculated as 0.033;Reference Ho, Koenig and Quek 7 and in a music festival, the PPR was found as 4.09.Reference Lund and Turris 9 Causes of these rates being higher in this study were associated with an open area that found people from all age groups under rough terrain, like Arbon indicated.Reference Arbon, Bridgewater and Smith 2 In Formula One Races, a part of the audience can watch both in seated areas and on a flat surface by standing. As to electronic dance music events, the audience participates during the event in a flat area, depending on whether the event is performed outdoors or indoors.
Limitations
The number of participants was limited by the official institutions providing the organization. Specially, the transport from the city center to the peninsula was hindered by the ferries’ restrictions. Since the region of the HNP is a peninsula, there may have been unauthorized transports from the northern part of the peninsula. Moreover, there may be small deviations in calculations of PPR, TTHR, and PDR because it couldn’t be reached the exact number of the health, safety, security, and other units like these in the region. For this reason, since the number of full participants is not known, it is not possible to calculate the error rate for the findings based on the impact of missing records. As there is no triage information on the forms, the severity of the patients has not been determined. As the hourly temperature data were not recorded on the days when the ceremonies were held, there was not analysis on the hours when the cases were referred to hospitals.
Conclusion
Within the scope of the 100th anniversary of the Gallipoli Wars, medical services were provided to the citizens of seven countries. Trauma was the most important phenomena of medical service offered. Land, sea, and air ambulances were used in patient transfers. In order to provide a better medical service for these ceremonies, which are held annually, in future studies, modelling can be done at the point of needs and estimations in the direction of the data of past organizations.
Acknowledgment
The authors would like to thank İlknur Cura, an Emergency Medical Technician from Çanakkale Provincial Directorate of Health who helped the collection of necessary data during the study, and Prof. Dr. Banu Güçiz Doğan from Hacettepe University, who made valuable contributions in regard to the manuscript.
