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EMS Mass Gatherings

Editor: Matt S. Friedman Updated: 10/27/2023 12:16:06 AM


The World Health Organization (WHO) defines mass gatherings as spontaneous or organized events with a large amount of attendees that challenge local resources.[1] The Federal Emergency Management Administration (FEMA) refers to them as “special events” that bring together many people large enough to affect the ability of the community to respond to a significant emergency.[2] Both of these definitions have emphasized the focus to be on the ability of the community to respond effectively and the resultant strain on essential resources rather than solely on the number of attendees. While the specific attendee threshold varies, most mass gatherings exceed 25,000 participants; however, the term could be broadened to include events involving more than 1,000 participants.[3] Essential resources include local emergency medical services (EMS), hospitals, transportation networks, and law enforcement.

Mass gatherings include concerts, sporting events, religious celebrations, street fairs, parades, and political rallies, each exhibiting distinct risk profiles. The nature of the event, whether bounded (eg, stadium events) or unbounded (eg, marathons), influences the associated risks. Additionally, concerts have an increased risk of recreational drug and alcohol use and injury from mosh pits, while sporting events could result in physical altercations. Religious gatherings attended by a higher percentage of older individuals introduce additional considerations.

Additional risks associated with mass gatherings include crowd disturbances, fires, structural collapses, disease outbreaks, terrorist attacks, stampedes, toxicological incidents, and environmental emergencies.[4] These gatherings become particularly vulnerable due to the sheer size of crowds, adverse weather conditions, infectious diseases, or food and water shortages or contamination.[5] Disease outbreaks present a heightened risk, with modes of transmission ranging from respiratory droplets to foodborne and skin contact, amplifying the potential for contagion.[6]

The defining characteristic of mass gatherings lies in their potential to strain local resources. This strain intensifies when confronted with a mass casualty incident (MCI) due to preexisting resource saturation, highlighting the need for comprehensive emergency planning and resource management.

Issues of Concern

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Issues of Concern

Goal of Health Care at a Mass Gathering Event

The objective of healthcare provision during mass gathering events, as outlined by the National Association of EMS Physicians (NAEMSP), encompasses several vital aspects. The first includes the initial onsite stabilization of individuals through administering necessary medications, treatments, and interventions. The second is to alleviate the strain on local EMS and nearby hospitals by reducing the influx of patients requiring medical attention. Lastly is utilizing the Incident Command System (ICS) to enhance preparedness and response capabilities for potential MCIs.[3] These measures aim to proactively prevent straining the local community healthcare system and manage medical care at the event separately within the capabilities of the event's medical system.


Effective planning for healthcare management at mass gathering events necessitates a comprehensive and collaborative approach among event organizers, sponsors, security personnel, EMS managers, the medical director, public health officials, and administrators from surrounding hospitals.[4] The process involves distinct phases, beginning with preplanning and moving through planning, operations, and post-event reviews. The planning phase focuses on onsite preparation, resource allocation, and personnel organization. Event management should review and approve plans at least 30 days before the event occurs. The operations phase encompasses the duration of the gathering, with healthcare resources and personnel actively addressing any medical needs. The post-event review focuses on what went well and what improvements could be made for future mass gatherings.

The planning of resources for an event is a multifaceted endeavor that is contingent upon multiple factors. Each event is uniquely defined by its anticipated attendance, duration, involved agencies, demographic of attendees, substance policies, historical data, venue type (outdoor versus indoor), expected attendee mood and behavior, and the age distribution of participants. Resource allocation largely depends on the event's size and character. Naturally, larger events with a significant presence of young and elderly attendees, concerts, and outdoor events often demand more resources. Necessary provisions extend beyond medical care and include essentials such as water, sanitation facilities, food provisions, and contingency shelters to shield attendees from unforeseen adverse weather.[4] A risk stratification scoring model, which factors in variables like environmental conditions, attendance numbers, alcohol consumption, crowd demographics, and crowd intentions, can be valuable in predicting resource utilization.[7]


In orchestrating healthcare services for mass gathering events, a critical consideration involves adhering to the local regulations and state requirements that vary from location to location. Different states and cities impose distinct constraints, encompassing staffing mandates and permit prerequisites. These regulations necessitate that each medical provider possesses certifications following the specific expectations of the locale. Additionally, certain locations recommend response timeframes for medical interventions, such as Basic Life Support (BLS) within four minutes, Advanced Life Support (ALS) within eight minutes, and timely transport to a medical facility within 30 minutes.[8] The states of New York, Pennsylvania, Maryland, Georgia, Iowa, Oregon, and Washington, D.C. have enacted legislation stipulating minimum standards for onsite medical resources during mass gathering events.[4]

Venue and Site Mapping

As part of the planning process, careful consideration is given to the venue itself. A comprehensive map delineates vital elements such as venue boundaries, strategically positioned medical stations, well-defined evacuation and travel routes, designated air landing zones for aeromedical support, and marked entry and exit points.[3] Areas of attendee egress should be twice as large as points of entry. Specialized traffic routes should be designated for efficient movement of EMS vehicles, ensuring rapid access to critical locations. Venue medical care facilities should be strategically placed throughout, emphasizing patient privacy, ease of access, and recognizability, often facilitated through prominent signage. Furthermore, allocating suitable areas for jurisdictional EMS teams and positioning security personnel are carefully addressed. 

Staffing, Personnel, and Security

Staffing, personnel, and security considerations are paramount when planning large events. To ensure smooth operations and the well-being of participants, the organizers must determine the appropriate staff ng requirements and their specific roles. This encompasses delineating treatment areas, providing both BLS and ALS capabilities, and having specialized personnel on site, such as physicians and qualified nursing staff if the event requires medical care beyond the EMS scope of practice. It is recommended to have 1 physician for every 5,000 to 50,000 attendees, 1 nurse for 2,600 to 15,000 attendees, and 1 EMT for every 2,600 to 65,000 attendees.[2] It's crucial to utilize prior patient presentation rates (PPR) and transfer to hospital rates (TTHR) from previous or analogous events to determine staffing needs and estimation of resources. Previous events studied received an average range of 0.5-2 medical calls per 1,000 spectators.[9] During mass gathering events, there is a noticeable rise in the workload for EMS, particularly reaching its peak during the night hours, and can, therefore, increase the demand for hosting resources in the surrounding area.[10] The underestimation of medical needs can significantly strain available EMS resources. Therefore, unforeseen incidents requiring extensive resources should be accounted for, such as infectious disease outbreaks, structural collapse, fires, stampedes, or terrorist attacks. Event budgetary constraints often limit staffing, typically leaving events underprepared for MCIs. Additionally, uniforms for licensed or credentialed personnel should be distinct from those of volunteers to avoid confusion.[4] Using volunteers in central staging or training areas has proven to be a successful strategy in many events.

The types of response capabilities at events or large gatherings can vary widely, tailored to each situation's unique needs and challenges. First aid stations serve as the primary touchpoint for immediate medical care. Patients can receive treatment at these stations and then seamlessly return to the event. These stations can take various forms, from fixed facilities to tents or mobile vans. Field hospitals may be established for larger events to provide more comprehensive care. Another essential component is the mobile team, which typically includes two personnel trained at the EMT level or higher who can navigate the event grounds via foot, bike, motorized transports, or even boats for water-based events.[4] These teams are equipped with stair chairs and gurneys and are adept at providing immediate services.

Security at mass gathering events is of paramount importance for several reasons. Firstly, it ensures attendees' safety and well-being, helping prevent accidents, injuries, and potential threats. Security is also essential for responding to violence and can mitigate the risk of stampedes and crowd-control-related incidents, which are common at large gatherings. The primary areas of emphasis within the security and surveillance strategy should encompass surveillance, water and fire safety, communication coordination, disaster response planning, traffic management, crowd control, and infrastructure development.[11]


Planning for events in various environments necessitates careful consideration of potential risks and challenges associated with the specific surroundings. For instance, when dealing with a high heat index, there's an increased risk of heat-related illnesses. Therefore, ample water, shade, fans, misters, and cooling systems should exist. Conversely, cold weather events require strategies and resources to facilitate rewarming capabilities. Additionally, outdoor venues often present unique challenges. They are frequently associated with lower extremity injuries due to uneven terrain.[4] Furthermore, the outdoor environment can expose attendees to risks such as envenomation, trauma, asthma exacerbations, allergic reactions, and skin rashes. One study found the most frequent chief complaints at outdoor events to be burns, fractures, contusions, and skin wounds.[12]

Roles of the Medical Director, EMS, and Physicians

The Medical Director plays a pivotal role in event medical management, embodying knowledge in EMS, treatments, logistics, resource management, and emergency medical conditions. The primary goal under their guidance is to effectively triage, stabilize, and determine transport needs for severe illnesses or injuries. For minor injuries, the emphasis is on providing onsite care, which not only aids the affected individual quickly but also helps conserve local EMS and neighboring hospital resources. The Medical Director is instrumental in planning medical care, overseeing the event safety plan, managing EMS clinician credentialing, enhancing treatment capabilities, and orchestrating preplanning for MCIs.

The role of EMS at events is multifaceted. As mobile medical first responders, they are often the initial point of contact for medical emergencies. Depending on the event's setup, EMS can act as the primary or secondary medical responder onsite. Their responsibilities include transporting patients within the venue boundaries or to external hospital facilities. Physicians and nurses are often integrated into the EMS team to enhance the breadth and depth of onsite medical care. Physicians have the additional ability to provide immediate treatment, such as advanced wound care or chemical sedation. Many events also practice the treat-and-release model, where paramedics provide treatment independently, and the patient is released back to the event. Previously, this was associated with concern for a high risk of adverse outcomes. However, with physician oversight providing the approval for discharge, this model has been successful.[4] Each member operates within their specific scope of practice, and the roles and expectations for each team member are explicitly defined and communicated before the event to ensure smooth and efficient operations.


Effective communication is paramount to the successful handling of emergencies at events. It facilitates the relay of crucial information and prepares teams for potential MCIs. To ensure continuous and uninterrupted contact, at least two modalities should be in place, typically a combination of phones and radios.[2] This dual-mode contact bridges the gap between medical oversight and field providers and between medical oversight and external local entities like EMS, fire department, 911 dispatch, public safety answering points (PSAP), and emergency departments. It's vital to have a dedicated medical channel, separate from the general event communications, with a preestablished channel specifically for MCIs.


Transport from events involves a multifaceted approach to ensure timely and adequate medical care. ALS/BLS ambulances should be readily available for ground transportation of patients. Air transport becomes viable when the distance to the nearest hospital is considerable or ground transport is delayed due to crowds or traffic. Onsite physicians play a crucial role in making informed decisions about the necessity and severity of transport. Onsite physicians have been shown to reduce ambulance transport by 89%.[13] This expertise aids in preserving valuable EMS and emergency department resources by determining efficient patient disposition and potentially reducing unnecessary transports.


Documentation remains essential even in medical event management. Every patient encounter, irrespective of the complaint's severity, should be recorded on a patient care record. It plays a vital role in addressing liability concerns, tracking equipment usage, potentially facilitating reimbursement, and providing valuable data for the planning of future events.[2] Ensuring thorough and consistent documentation safeguards the medical team and the event attendees.

Mass Casualty Incidents

MCIs require a preplanned response to manage the surge in medical needs effectively, and the Incident Command System (ICS) serves as a unified platform, ensuring seamless communication across various facets of the response team. The process begins by activating the event emergency plan, with the command center being alerted by onsite personnel about the incident specifics, potential hazards, the estimated number of patients, necessary resources, and the optimal route for resource delivery.[8] The command center then communicates with the local 911 center, which activates the local or regional MCI plan and promptly notifies surrounding hospitals. Medical providers then shift to their predefined MCI officer roles. Stored supplies tailored for MCI scenarios are then employed, and a systematic triage classification—categorized as red, yellow, green, or black—is initiated to prioritize care. In case of an MCI at a mass gathering, the venue should feature two triage zones, designated ambulance loading zones, and an ambulance staging area.[4] The role of security personnel becomes paramount in such scenarios to prevent stampedes or asphyxiation injuries, which can exacerbate an already precarious situation.

Planning is critical, especially in anticipating the capacities of surrounding hospitals. Proactive measures should be undertaken well in advance, such as pre-assigning MCI leadership roles, earmarking disaster communication channels, and coordinating with regional hospitals. Equally important are providing ample supplies, formulating strategies to conserve local resources, and contacting jurisdictional authorities when event resources are stretched thin to signal the need for reinforcements.

Post-event Review

A post-event review is critical for continuous improvement and learning for event organizers and medical teams. This review should entail a comprehensive assessment of the adequacy of the medical care provided and the effectiveness of the pre-event planning. Essential metrics like the PPR, TTHR, the incidence of specific medical event types, and the number of patients presenting with specific conditions should be examined in detail.

Quantifying patient presentations and onsite care during events offers a data-driven approach to understanding medical needs and challenges. A critical measure is the time to access a severely sick or injured patient. Two vital metrics used to gauge the extent of medical care needed are the Medical Utilization Rate (MUR) and the Patient Presentation Rate (PPR), typically quantified per 1,000 or 10,000 attendees.[14] Research indicates that factors like hot weather, crowd mobility, alcohol availability, venue type, and the number of medical personnel present can elevate the PPR.[4] The Transport to Hospital Rate (TTHR) helps understand the impact of onsite care on the EMS and neighboring hospital systems. A study analyzing EMS records from diverse mass gatherings between 2009 and 2011 revealed that most patient presentations required minor support, with 95.97% being mild in severity.[15] Ultimately, these metrics aid in assessing the demand and anticipating the necessary medical care for each event based on prior similar events. Additionally, discussing the successes and failures can provide invaluable insight into the challenges faced during the event and will assist the planning and execution of similar future events.

Clinical Significance

Managing healthcare services during mass gatherings is a complex task that requires careful planning, coordination, and collaboration among various stakeholders. The focus must be on stabilizing individuals, reducing the burden on local healthcare resources, and preparing for potential emergencies. Clear roles, effective communication, and data-driven analysis are crucial to success in ensuring the safety and well-being of attendees at these events.

Proper planning and analysis of mass gathering events is essential for multiple reasons. Mass gatherings involve thousands of people. Understanding how to plan for and manage these events is crucial for ensuring public safety and minimizing the risk of accidents, injuries, or emergencies. Additionally, given the large number of people in a small space, there is a high risk of spreading infectious diseases. Understanding how to implement health measures to prevent disease transmission is essential. Mass gatherings also pose a risk of natural disasters or terrorist attacks. Preparing for such incidents, including evacuation plans and emergency medical care, is vital to protect attendees. Resource management at these events is crucial to provide care and establish communication channels to coordinate response. Knowing how to plan for a mass gathering event is essential for public safety, disaster preparedness, emergency response, efficient resource allocation, effective communication, and community engagement, ensuring the event is enjoyable and safe for all.

Mass gatherings have a significant impact on healthcare systems and services. These impacts can vary in scale depending on the size of the event, location, and the level of preparedness. With the influx of attendees comes an increase in demand for healthcare services, both minor and critical. The potential for a surge in emergency room visits can strain the resources of local emergency departments and hospitals. Similarly, transportation and ambulance services can be heavily impacted, responding to a higher call volume and necessitating additional vehicles and personnel. Mass gatherings have the potential to strain healthcare systems by increasing demand for services and creating potential health risks, stressing the importance of proper planning and preparedness to ensure the system in place can respond effectively to the challenges posed by mass gatherings.

Enhancing Healthcare Team Outcomes

Health professionals, such as physicians, nurses, and pharmacists, must collaborate effectively with various stakeholders, including event organizers, security, EMS managers, and public health officials, to provide healthcare services during mass gatherings. Efficient resource management is crucial to prevent overwhelming local resources. All agencies and stakeholders must work together to triage, provide medical care, manage trauma, and stabilize patients during emergencies, particularly mass casualty incidents (MCIs). Clear roles and responsibilities must be defined for healthcare professionals within the team, specifying their scope of practice and authority during mass gatherings. Effective communication between the healthcare team and external stakeholders like EMS and security personnel is vital for patient care during mass gatherings. Coordinating patient transport, whether by ground or air, requires close collaboration among healthcare professionals, EMS staff, and physicians to determine the most suitable mode of transportation based on patient needs and available resources. Active participation in comprehensive emergency planning for mass gatherings is essential. These plans should cover resource allocation, communication, and responses to MCIs.



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