Healthcare providers at mass gathering events may deliver basic, intermediate, or critical care interventions in accordance with their scope of practice. Early identification of the goals of mass gathering medical care allows stakeholders to address risk assessments and develop medical plans to appropriately employ community healthcare resources. The Event Medical Director plays a pivotal role in pre-event planning, event medical care delivery, and post-event analyses for continuous quality improvement.

The mass casualty incident marks the ultimate challenge for emergency services at a mass gathering event. This chapter provides a thorough review of the unique challenges associated with the occurrence of a mass casualty incident in a mass gathering setting and summarizes a comprehensive, flexible framework to manage this specific scenario. In particular, we provide a detailed summary of the evidence and recommendations associated with the prevention, preparedness, response, and recovery efforts related to mass casualty incident management at a mass gathering event. Our discussion of prevention focuses on proper risk assessment practices and a recommended set of effective measures that can be used to promote crowd management within the mass gathering setting. Our section on disaster preparedness highlights the critical initial step to identify and engage all stakeholders associated with the mass gathering event and the particular disaster scenarios identified in the event’s risk assessment profile, as well as key measures to establish clear disaster plans and promote organized command and communication. Finally, specific recommendations are provided for efficient disaster response through the initial and longer-term phases, as well as for the recovery process that includes effective community support and psychological first aid for affected parties.

For large entertainment tours composed of 100 to 200 personnel moving from one city (or country) to another every few days over several months’ time, the odds of numerous untoward health events occurring, some very serious, become reasonably high. Beyond rigorous schedules and living/dining in close quarters, understandable reticence to abandon one’s post can occasionally delay timely care. Accordingly, having veteran medical specialists as part of the touring team has been found to be invaluable, not only for pre-emptive minor interventions and continuity of care, but also for immediate, expert handling of serious emergencies. Experienced, well-connected touring medical specialists also provide prospective contingency plans for each destination city and venue. These medical advance plans detail the most-knowledgeable local physicians or facilities for best managing any respective medical condition. They also identify the local “point-persons” to contact for coordination of true emergencies and especially if there is a need for multi-casualty incident management at the venue. They anticipate health risks such as air quality, altitude sickness, endemic disease vectors and other concerning threats at each destination. They also train touring staff in basic life support, bleeding control and emergency equipment readiness. Touring specialists should also be well-integrated into security team functions.

Mass gatherings create challenges for timely and efficient medical response. Compounded by exceptional noise from cheering crowds and ambient entertainment, compacted audiences form predictable barriers to patient sightings and access. Timely access also may be complicated by steep arena stairwells or poorly-defined locations along a longitudinal raceway, parade, or beachside festival. On-scene responders often encounter fixed barricades, inebriated crowds, obtrusive noise, and relative distances from on-site medical aid centers. Very often, potentially ill or injured persons are adamantly set against leaving their coveted position in the audience having purchased expensive tickets, traveled far and awaited many months, or even years, to be there. Once retrieved, patients need to be conveyed with protective measures and evaluated appropriately despite resource-limited settings and often pervasive heat, humidity and intoxication. Accordingly, patient identification, intra-site retrieval, evacuation, tracking, and communications need to be optimally planned and well-coordinated to mitigate these challenges. Recent experiences have provided evolving insights into best practices for mass gathering medical professionals. Many are addressed within this discussion including definitions for reportable patients, use of spotters and geospatial applications, coordinated tandem response with security personnel, dedicated record-keepers at medical care sites and electronic tracking devices for vulnerable populations and even entire audiences.

The Incident Command System (ICS) is a standardized command and control structure that is used in the management of incidents such as mass gathering events. It provides a common structure by which to organize responders. The ICS ensures that responders operate based on a common operating picture or algorithm?. Based on the core criteria of unity of command and management by objective, the Incident Command Structure delineates specific roles and reporting responsibilities and can be expanded to fit the incident at hand. When implemented in a planning process prior to a mass gathering event, the Incident Command System can aid in ensuring responders mitigate emergencies safely and efficiently.

Motorsport medicine is a unique version of Emergency Medicine. If the medical provider-leader has been asked to participate in a motorsport event, he/she will be dealing with traumatic injuries, large crowds, and weather issues in a location that will be remote from the hospital. Depending on the type of motorsport, knowledge of injury patterns will as-sist the practitioner in medical decision making. All the principles discussed will have bearing on whatever form of motorsport that will be encountered, potentially with some modifications. Providing care at a motorsport event has changed drastically over the past few decades. Expectations are higher, bad outcomes more visible, and technology is pushing drivers to the limits of their endurance. In the past, medical care was an after-thought by most event promoters. Now, proper medical coverage and protocols need to be in place prior to most high profile motorsport events or the “show will not go on.” This strategy does require planning ahead of time, involvement of local resources and this section will assist in preparation for this approach. A suggested equipment and medica-tion list are also provided.

While all mass gatherings create significant challenges for delivering optimal medical care, music concerts and festivals engender additional concerns ranging from a higher likelihood of toxicological, topographical, meteorological and sociological risks to additional threats from violence, injury and even food-borne illness. Locating patients can pose challenges among packed audiences in the dark and din of massive crowds and blaring entertainment. Multi-day music-related festivals, particularly those including on-site overnight camping, can pose additional and often escalating risks day-by-day.

Planning risk assessments can be multi-variate and dynamic in nature. Medical planners may first tailor plans based on historical experiences, evolving new intelligence or even developing external threats, but available tools for calculating risk for each type of threat can better quantify concerns and justify additional funding and resources for the best possible medical care and health security. Beyond basic considerations such as estimated crowd size and density, location of the venue, and event-specific medical considerations, mass gathering medicine clinicians and planners need to navigate some variable considerations including climate, weather, type of event, specific site structures, the organizers’ expectations and even typically unanticipated types of events such as terrorism, stampedes, contaminated food and some previously-unrecognized lethal drugs being passed around to attendees.

Mass gatherings create challenges to timely medical response. These challenges become amplified when medically and sociologically vulnerable individuals attend. Such at-risk persons may include, but certainly are not limited to, pregnant women, children, the elderly, people with chronic medical conditions, and those with one or more forms of disabilities. When planning for mass gatherings, or when directly managing large assemblies of persons that have evolved subsequent to mass evacuations of displaced persons retreating from a disaster, military conflict, or other humanitarian crisis, experience has shown that prospective preparedness and contingency planning addressing the needs of the entire community, including at-risk populations, facilitates better outcomes for all. Depending on the specific mass gathering, there will always be a variation in the unique concerns, event-driven nuances and potential at-risk populations in attendance for each. However, one recommended generic strategy to help provide a more unified and methodical approach to planning for at-risk persons is the Communication, Maintaining Health, Independence, Support and Safety and Transportation (CMIST) Framework. The CMIST framework has been shown to an extremely useful tool that can help event organizers and emergency managers better anticipate the various needs of these at-risk populations under a variety of mass gathering scenarios worldwide.

Incidents of civil unrest are increasing in frequency across the United States and may involve protests or demonstrations in response to political or economic activities, responses to concerts or sporting events, or in response to controversial actions by law enforcement. During these incidents, injuries may occur either in isolation or in associated interactions with law enforcement personnel. There are specific patterns of injury that are unique to protests and encounters with law enforcement, and it is important for the urban emergency medicine practitioner to have a fundamental understanding of the management of common injuries associated with law enforcement interactions. This chapter will highlight the general principles of emergency department care during periods of civil unrest, including best practices for interacting with both public safety personnel and private citizens. Patterns of injury will be explored, including injuries occurring from kinetic impact projectiles, conducted electrical weapons, and crowd dispersal agents, in addition to other less-common injury patterns encountered during periods of civil unrest.