Andrew Milsten

Mass-gathering medical care: a review of the literature.

UNLABELLED Mass-gatherings events provide a difficult setting for which to plan an appropriate emergency medical response. Many of the variables that affect the level and types of medical needs, have not been fully researched. This review examines these variables. METHODS An extensive review was conducted using the computerized databases Medline and Healthstar from 1977 through May 2002. Articles selected contained information pertaining to mass-gathering variables. These articles were read, abstracted, analyzed, and compiled. RESULTS Multiple variables are present during a mass gathering, and they interact in complex and dynamic ways. The interaction of these variables contributes to the number of patients treated at an event (medical usage rate) as well as the observed injury patterns. Important variables include weather, event type, event duration, age, crowd mood and density, attendance, and alcohol and drug use. CONCLUSIONS Developing an understanding of the variables associated with mass gatherings should be the first step for event planners. After these variables are considered, a thorough needs analysis can be performed and resource allocation can be based on objective data.

Hospital responses to acute - onset disasters : A review

INTRODUCTION Hospitals the world over have been involved in disasters, both internal and external. These two types of disasters are independent, but not mutually exclusive. Internal disasters are isolated to the hospital and occur more frequently than do external disasters. External disasters affect the community as well as the hospital. This paper first focuses on common problems encountered during acute-onset disasters, with regards to hospital operations and caring for victims. Specific injury patterns commonly seen during natural disasters are reviewed. Second, lessons learned from these common problems and their application to hospital disaster plans are reviewed. METHODS An extensive review of the available literature was conducted using the computerized databases Medline and Healthstar from 1977 through March 1999. Articles were selected if they contained information pertaining to a hospital response to a disaster situation or data on specific disaster injury patterns. Selected articles were read, abstracted, analyzed, and compiled. RESULTS Hospitals continually have difficulties and failures in several major areas of operation during a disaster. Common problem areas identified include communication and power failures, water shortage and contamination, physical damage, hazardous material exposure, unorganized evacuations, and resource allocation shortages. CONCLUSIONS Lessons learned from past disaster-related operational failures are compiled and reviewed. The importance and types of disaster planning are reviewed.

Variables influencing medical usage rates, injury patterns, and levels of care for mass gatherings.

OBJECTIVES Mass gatherings create difficult environments for which to plan emergency medical responses. The purpose of this study was to identify those variables that are associated with increased medical usage rates (MURs) and certain injury patterns that can be used to facilitate the planning process. METHODS Patient information collected at three types of mass gatherings (professional American football and baseball games and rock concerts) over a three-year period was reviewed retrospectively. Specific variables were abstracted: (1) event type; (2) gender; (3) age; (4) weather; and (5) attendance. All 216 events (total attendance 9,708,567) studied were held in the same metropolitan region. All MURs are reported as patients per 10,000 (PPTT). RESULTS The 5,899 patient encounters yielded a MUR of 6.1 PPTT. Patient encounters totaled 3,659 for baseball games (4.85 PPTT), 1,204 for football games (6.75 PPTT), and 1,036 for rock concerts (30 PPTT). The MUR for Location A concerts (no mosh pits) was 7.49 PPTT, whereas the MUR for the one Location B concert (with mosh pits) was 110 PPTT. The MUR for Location A concerts was higher than for baseball, but not football games (p = 0.005). Gender distribution was equal among patrons seeking medical care. The mean values for patient ages were 29 years at baseball games, 33 years at football games, and 20 years at concerts. The MUR at events held when the apparent temperature was 80 degrees F significantly lower statistically than that at events conducted at temperatures <80 degrees F were (18 degrees C) (4.90 vs. 8.10 PPTT (p = 0.005)). The occurrence of precipitation and increased attendance did not predict an increased MUR. Medical care was sought mostly for minor/basic-level care (84%) and less so for advanced-level care (16%). Medical cases occurred more often at sporting events (69%), and were more common than were cases with traumatic injuries (31%). Concerts with precipitation and rock concerts had a positive association with the incidence of trauma and the incidence of injuries; whereas age and gender were not associated with medical or traumatic diagnoses. CONCLUSIONS Event type and apparent temperature were the variables that best predicted MUR as well as specific injury patterns and levels of care.

Injury Patterns and Levels of Care at a Marathon

INTRODUCTION Marathons pose many challenges to event planners. The medical services needed at such events have not received extensive coverage in the literature. OBJECTIVE The objective of this study was to document injury patterns and medical usage at a category III mass gathering (a marathon), with the goal of helping event planners organize medical resources for large public gatherings. METHODS Prospectively obtained medical care reports from the five first-aid stations set up along the marathon route were reviewed. Primary and secondary reasons for seeking medical care were categorized. Weather data were obtained, and ambient temperature was recorded. RESULTS The numbers of finishers were as follows: 4,837 in the marathon (3,099 males, 1,738 females), 814 in the 5K race (362 males, 452 females), and 393 teams in the four-person relay (1,572). Two hundred fifty-one runners sought medical care. The days temperatures ranged from 39 to 73 degrees F (mean, 56 degrees F). The primary reasons for seeking medical were medication request (26%), musculoskeletal injuries (18%), dehydration (14%), and dermal injuries (11%). Secondary reasons were musculoskeletal injuries (34%), dizziness (19%), dermal injuries (11%), and headaches (9%). Treatment times ranged from 3 to 25.5 minutes and lengthened as the day progressed. Two-thirds of those who sought medical care did so at the end of the race. The majority of runners who sought medical attention had not run a marathon before. CONCLUSIONS Marathon planners should allocate medical resources in favor of the halfway point and the final first-aid station. Resources and medical staff should be moved from the earlier tents to further augment the later first-aid stations before the majority of racers reach the middle- and later-distance stations.

Retrospective Analysis of Quality Improvement Throughput Measures at a High‐Volume Community Emergency Department

Objective: To assess the effect of having a physician or physicians assistant (PA) as patients’ first point of contact in our emergency department (ED) on the rate of leaving without being seen (LWBS) and wait time. Methods: In before and after intervention conducted in the ED at a 265‐bed community hospital, data were collected on all patients presenting to the ED during a 70‐month period. A physician or PA was stationed in triage 16 hr a day. The screening process included measurement of vital signs, a brief history and physical examination, and computerized physician order entry. Results: During the study period, volume increased from 86,000 to 102,000 patients per year. Monthly averages for ED visits increased 16%, admissions increased 5%, and ambulance visits increased 18%. The rate of LWBS decreased from 3.1% to 1.7%. Door‐to‐doctor time decreased by 14 min. Conclusions: Despite an increase in patient census, the LWBS rate and door‐to‐doctor time decreased. This study of one solution to the issue of ED crowding demonstrates how a process redesign can lead to successful changes in throughput metrics.

High-Amplitude Atlantic Hurricanes Produce Disparate Mortality in Small, Low-Income Countries

OBJECTIVES Hurricanes cause substantial mortality, especially in developing nations, and climate science predicts that powerful hurricanes will increase in frequency during the coming decades. This study examined the association of wind speed and national economic conditions with mortality in a large sample of hurricane events in small countries. METHODS Economic, meteorological, and fatality data for 149 hurricane events in 16 nations between 1958 and 2011 were analyzed. Mortality rate was modeled with negative binomial regression implemented by generalized estimating equations to account for variable population exposure, sequence of storm events, exposure of multiple islands to the same storm, and nonlinear associations. RESULTS Low-amplitude storms caused little mortality regardless of economic status. Among high-amplitude storms (Saffir-Simpson category 4 or 5), expected mortality rate was 0.72 deaths per 100,000 people (95% confidence interval [CI]: 0.16-1.28) for nations in the highest tertile of per capita gross domestic product (GDP) compared with 25.93 deaths per 100,000 people (95% CI: 13.30-38.55) for nations with low per capita GDP. CONCLUSIONS Lower per capita GDP and higher wind speeds were associated with greater mortality rates in small countries. Excessive fatalities occurred when powerful storms struck resource-poor nations. Predictions of increasing storm amplitude over time suggest increasing disparity between death rates unless steps are taken to modify the risk profiles of poor nations. (Disaster Med Public Health Preparedness. 2016;10:832-837).

Retrospective Analysis of Mosh-Pit-Related Injuries

OBJECTIVES Moshing is a violent form of dancing found world-wide at rock concerts, festivals, and electronic dance music events. It involves crowd surfing, shoving, and moving in a circular rotation. Moshing is a source of increased morbidity and mortality. The goal of this study was to report epidemiologic information on patient presentation rate (PPR), transport to hospital rate (TTHR), and injury patterns from patients who participated in mosh-pits. Materials and Methods Subjects were patrons from mosh-pits seeking medical care at a single venue. The events reviewed were two national concert tours which visited this venue during their tour. The eight distinct events studied occurred between 2011 and 2014. Data were collected retrospectively from prehospital patient care reports (PCRs). A single Emergency Medical Service (EMS) provided medical care at this venue. The following information was gathered from each PCR: type of injury, location of injury, treatment received, alcohol or drug use, Advanced Life Support/ALS interventions required, age and gender, disposition, minor or parent issues, as well as type of activity engaged in when injured. RESULTS Attendance for the eight events ranged from 5,100 to 16,000. Total patient presentations ranged from 50 to 206 per event. Patient presentations per ten thousand (PPTT) ranged from 56 to 130. The TTHR per 10,000 ranged from seven to 20. The mean PPTT was 99 (95% CI, 77-122) and the median was 98. The mean TTHR was 16 (95% CI, 12-29) and the median TTHR was 17. Patients presenting from mosh-pits were more frequently male (57.6%; P<.004). The mean age was 20 (95% CI, 19-20). Treatment received was overwhelmingly at the Basic Life Support (BLS) level (96.8%; P<.000001). General moshing was the most common activity leading to injury. Crowd surfing was the next most significant, accounting for 20% of presentations. The most common body part injured was the head (64% of injuries). CONCLUSIONS This retrospective review of mosh-pit-associated injury patterns demonstrates a high rate of injuries and presentations for medical aid at the evaluated events. General moshing was the most commonly associated activity and the head was the most common body part injured. Milsten AM , Tennyson J , Weisberg S , Retrospective analysis of mosh-pit-related injuries. Prehosp Disaster Med. 2017;32(6):636-641.

Mass Gathering Medical Care: Resource Document for the National Association of EMS Physicians Position Statement

Abstract Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre–event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the communitys medical care system, while fulfilling the needs of event participants. Key words: mass gathering medicine; event medicine; event medical care planning; EMS medical director; prehospital

Disaster medicine and emergency preparedness training for health care institutions.

CEEPET’s mission is to provide competency-based emergency preparedness education and training, using an all-hazards approach, to staff members of hospitals, community health centers, long term care facilities, and emergency medical service providers. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.