Mass Event Zone Planning

Mass Event Coverage: Avoiding the EMS Quagmire

By:

William C. Butler II, NREMT-B, President;

and

David E. Gesner, NREMT-P, MA., Director;

Marshall University Emergency Medical Services

400 Hal Greer Blvd.

Huntington, WV 25701

.(304)696-2391/ 6652 / 6683

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Emergency Medical Services organizations have for years attempted to find new methods and protocols in their effort to minimize response time, scene time and total call time for emergency medical responses. More often than not, their attempts are fruitful and result in decreased patient morbidity and mortality. Many problem areas remain, despite tireless effort on the part of the providers and medical directors to resolve them. One area of concern to many EMS organizations is the best method to facilitate emergency medical coverage to what we have called a Mass Event. Simply, a mass event is any gathering of people where either the numbers of people or the size of the response area taxes the public safety resources of the responsible agency or agencies. The following discussion describes the problems and pitfalls common to mass event coverage from a prehospltal point ofview, two fairly common methods by which an EMS call is handled in the mass event situation, and the relatively new method by which Marshall University EMS provides emergency coverage in the mass event situations common to this organization.

We open at a college championship football game in a medium-sizedAppalachian city. The scene is one ofbarely controlled chaos, ifchaos is the correct word to describe the euphoria expressed by thirty-fIVe thousandfootballfans at their star player scoring the tie breaking touchdown ofa hardfought game. The frenzy builds to a crescendo of joyful screams and applause. The media pans the crowdfrom their sideline positions, capturing this story as it happens, hoping for that certain shot to make their day a productive one. Police and security officers strain to hear their radios while they watch the crowdfor trouble, or for that little lost child that was reported twenty minutes ago. Event officials are simultaneously overjoyed at the turnout and worried at the potential for problems with this many people presentfor their game. And in the middle ofit all--in the midst ofthis mania--a sixty-two year old woman suddenly realizes she's in seriolls trouble. She's felt this way before, seven years ago when she had her first heart attack. She spent two weeks in Intensive Care and months in rehabilitation. Her doctor told her she wouldn't survive another one ifshe didn 'tfollow his instructions and get herselffit again. She had another, much milder problem two years ago after deciding she was better and could live "free." She was home injust afew days, but swore she'd not let it happen again. This is different, however. She's dizzy and tired, having trouble breathing and her chest feels as though there's a car parked on it. She leans on her husband of thirty-six years and looks up at him, watches his face turn from great joy to intense fear, and sinks into unconsciousness. What do we, as Emergency Medical Technicians, do about this? How do we best provide for the medical coverage necessary in such situations? Why must our response in this case be different from our normal operating mode? The simplest answer that can be given is simply time. The best medicine we can ever give to any patient we encounter is time; more precisely, the less time, the better. If we can keep the elapsed time for the response to a minimum, we go a long way toward minimizing the patient's suffering and hopefully can prevent an untimely death. Few can argue with this statement. To understand the importance of preplanning a response path during an event similar to the one above, we must begin to understand the true uniqueness of this class of response areas. These situations are known by several names: concerts, rallies, ball games and so on. In EMS circles, they are not often thought of as a definable situation, merely a gathering of many potential patients. Many municipalities seem to regard these situations merely as a relocation of their patients to a more centralized area and may move another ambulance or two to the vicinity. little thought seems to have been given to the idea that the event itself is an important situation that must be looked at from a slightly different viewpoint. We have looked at it in depth and have even given it a name: the Mass Event. A mass event is defined within this framework as any event that places a strain on public safety resources because of: a) the number of people in attendance, b) the high ratio of attendees in a given area to public safety personne~ and c) the size of the facility or area in which they are gathered produces a high density population. They may range in size from a few hundred people participating in a Walk-a-Thon to the 1vfillion Man March in Washington, DC a few years ago to Woodstock n. These events present unique problems

for the Emergency Medical Services provider not encountered during a "normal" call. A major problem is that the potential for injury and illness during the event increases simply due to overcrowding, the emotional state of the attendees, the propensity for drink and revelry, and the like. During a mass event, the EMS providers are likely to have to ply their craft with an audience of gawkers, off duty medical professionals and paraprofessionals, and the media. All the while, the clock is ticking minutes off the "golden sixty" and the ''platinum ten." Every response plan to date seems to be very concerned with time. We see it on our run sheets, in the Emergency Department, the dispatch log sheets, and we have a running cadence in our heads as we package and treat each patient. When we try to perform our duties in an extremely crowded, noisy and dangerous atmosphere, we simply cannot treat the patient as we normally would in their home. We must take into account the dangers associated with working in the masses. We must be vigilant for our own safety and the patient's. We must be cautious when using advanced life support procedures (I've personally witnessed on two occasions the defibrillation of an entire row of spectators on metal bleachers!). We must also keep our eyes on the clock. It simply takes more time to move a patient in a crowd. The more we dawdle, the faster they die! Several major problems must be addressed and overcome for a mass event response plan to be effective. First and foremost is the lengthy response times common to these situations. A method must be found by which providers can get to the patients more quickly and safely. Provider fatigue is a factor, especially in the large sports stadiums cornmon to universities and large cities. If the EMTs must make their way up flight after flight of steep stairs carrying all their equipment while fighting the crowd, package the patient and extricate them back down those stairs to the ambulance, the likelihood of being injured or making mistakes on the call increases dramatically. Access to EMS is, ironically, more difficult in a sea of people due to the low relative visibility of public safety personnel and lack of easily accessed telephones (excluding cell phones, of course). Command and control of the response teams can provide either a solid foundation for the response or the weak link in the chain of events leading to the patient's death.

Frantically, her husband tries to awaken her with the full knowledge that if he can't get her to open her eyes, she'/I die. Panic-stricken, he gains the attention ofthe person standing beside him (who didn't notice the emergency because ofthe standing ovation and the noise) and sends him for help. This messenger tries to move down the packed row ofspectators to the aisle, where he hopes he'll find a security guard. He breaks into the open and looks toward the tunnel entrance to his section for the guards he saw earlier that day. He sees one cheering with the crowd and runs up several flights of stairs to him. The woman's husband is oblivious to everyone around him as he begins to weep. The example above is typical of the first stages of an emergency in any mass event scenario. Bystanders recognize the situation exists and try to take action. The most important step, however, has taken place long before the victim succumbs to her illness: the pre-planning of the event's medical coverage. The pre-plan covers all aspects of the chain of events from initial recognition to delivery of the patient to the Emergency Department, as well as team recovery back to the event site. Recognizing the importance

of each step in the call cycle is paramount to the effectiveness of the pre-plan and of the actual response. The pre-plan starts where the call starts...initial recognition of the emergency and rapid access to the medical teams there to provide coverage. We, as providers, cannot control the occurrences, but we can assist the victims by making access to EMS as simple and visible as possible. Every event official, from the ushers to the director, must be made aware of the importance of rapid action in dispatching medical teams to the scene. They should be made aware that official visibility will greatly decrease the time from onset of the "' illness or injury to the arrival of the medical team. A rapid response will assist in decreasing the morbidity/mortality of patients, and this in tum will keep liability (and maybe even insurance costs) to a minimum. This is one of the most important concepts of mass event medical·coverage and should not be taken lightly. As an aside, the proliferation of cellular phones today poses a unique problem for this situation. Calling 911 may actually increase the response time due to the addition of several more steps in the response chain. If the 911 dispatch center is not made aware of the method by which the event is covered and who is responsible, an ambulance from outside the mass event plan may be directed to the scene. In the time that it would take for an ambulance to respond, the patient may have been on his or her way to the hospital if the caller had simply spoken to security. Emergency dispatch centers need to be made aware of the event's intrinsic medical coverage so that they may refer the call to the event's command center for a more efficient response. Once access to EMS has been gained, the focus of the response is on speed and efficiency. Prior to the event, EMS officials and rescue personnel need to go to the site and develop their specific response plan. Each plan is unjque to the event and must be developed in the light of the unique variables associated with the event. These variables include, but are not limited to, the physical size and layout of the site, the number of participants expected, the number of providers available, the EMS resources that can be utilized, availability of mutual aid from outside EMS sources, etc. Pathways of movement for the initial response teams, ambulance support and supporting agencies must be recognized and defined. An efficient method of intrinsic mutual aid must be developed should the need arise. And lastly, an event protocol should be developed that takes into account the unique structure of the response plan. Mapping the event site and providing a written directive for the medical teams is also most helpful. These authors will not attempt to provide a "unified theory of event coverage" that is a catch-all for every situation. We will merely discuss the methods by which we cover mass events at Marshall University and the surrounding area. From this discussion, we hope to stress the importance of pre-planning the coverage and demonstrate the method by which we've arrived at our current plan. There seem to be two primary methods by which mass event coverage responses are done. These are defined by these authors as the Unit Team method and the Zone Team method. Unit Team responses are those in which the responding medical team has control of the patient from initial dispatch to the ambulance's arrival at the ED. They carry all necessary equipment to effect the response and maintain patient contact throughout the call cycle. This is how EMS responses in the normal prehospital environment usually work. Two significant types of Unit Team response strategies are the Central Unit Team and the Dispersed Unit Team strategies. The Central Unit Team strategy is most like

''nonnal'' EMS in that all EMS resources and personnel are dispatched out of a single staging area. The Dispersed Unit Team strategy is one in which the individual teams are placed in strategic locations and, with patient in tow, meet the ambulance at a designated transport point. Usually, with this last strategy, a "flying" equipment pool responds to the patient location to provide bulky items to the team, so as to avoid an extremely large equipment requirement (that way each team won't have to tote a cot around with them). The major advantages of the previous strategies are that the information from the patient/bystanders is less likely to be confused during transfer than if there were more than one team involved. The transporting crew goes to the scene itself and may be able to gain more information as to the nature of the call than might be transmitted between two teams. Patient rapport is likely to be more solid than if several teams are involved. Several major disadvantages exist,' however, that in our opinion are less desirable than the advantages gained. First, and possibly most important, is team fatigue. In many cases, the access­ extrication distance and situation are long and difficult. Fatigue leads to judgment errors and increases the likelihood of provider injury. Of these plans, the Central Unit Team plan has the longest response time and the highest probability of provider fatigue. In an event (such as a small walk-a-thon) where these methods are effective, it is most easily adapted to by providers and yields more solid patient rapport. The Dispersed Unit Team plan has much shorter response times, but may yield high levels of provider fatigue as the teams extricate the patient all the way to the waiting ambulance. Mutual aid during the call is as slow or slower and just as tiring as the initial response. We have tried variations of these methods and found them inefficient for the reasons stated above (and others) and have attempted to develop a more efficient plan for our needs. Marshall University EMS provides coverage for several different mass event scenarios during the year and we needed to develop a flexible plan that we could adapt to each of these. Primarily, our concern has focused on the NCAA sporting events held at any of our major facilities during the school year. We have a medium sized basketball arena and a 33,150 seat football stadium within our response area on the MU campus. Several times each year, the campus swells with spectators and participants, as well as our nonnal campus population, and we must be able to quickly and efficiently provide medical response to everyone within our district. MUEMS is a volunteer service, and as such, we may have more or less the numbers of personnel required to provide effective coverage at an event using the previously-mentioned methods of coverage. We also maintain only one ambulance on campus and have needed to develop a plan for mutual aid while that single vehicle is engaged on a call. To efficiently utilize our limited personnel and resources, we have developed what we call the Zone Team method of coverage. The Zone Team plan is a tiered response plan that was developed by a fusion of wartime military medical response methods, civilian EMS methods, and mass casualty incident response plans. Simply put the response area is divided into Central Command Zones of coverage and there are teams ~ithin those zones pre-positioned to affect an immediate response. A Central Command Zone, or CCZ, is analogous to an EMS district. It has its own command and control and its own director. It functions as a separate entity and possesses its own resources. Each CCZ should have its own command! dispatch center, but several may be able to function under a single command/dispatch center if it is organized well.

Each CCZ is divided into major zones of response. Each zone has a single roving Advanced Life Support (ALS) team with all necessary equipment for the extrication of a patient from the scene (i.e. cot, stair chair, spine board, etc.) as well as for ALS-Ievel treatment. These zones are further divided into primary response areas where Basic Life Support (BLS) teams are stationed. In many cases, the BLS teams are the initial point of contact for the access into the EMS system as they have such a high visibility within their areas, yielding extremely short response times. The ALS teams are responsible for the '··r· BLS teams in their zone and provide a basic level of command and control as well as mutual aid should the BLS team require it. The director (or the designated assistant) provides command and control for the ALS teams within their CCZ. Each call is treated like a rescue in that it follows the LASET (Locate, Access, Stabilize, Extricate, Treat! Transport) method. Each CCZ is also divided into major transport zones and defined transport points are established where the ambulance meets the patient. Each transport team is staffed and equipped the same as the ALS rove teams because they provide mutual aid to the rove teams while they are engaged with a call (in other words, dispatch will designate a transport team to act as an ALS rove team until the original team clears from the call). Each transport zone has its own assigned ambulance that responds to transport patients to the hospital. The command and control element consists of the director, a designated assistant and the command center. The director is responsible for all areas and actions within the CCZ. He usually refrains from direct patient contact, as his primary role is direction of the response (a traffic cop, if you will). The designated assistant provides on scene command support, direction and medical assistance if necessary. He is the on scene eyes and ears for the director and ensures the response chain moves as planned. He also may provide the rapport link for the patient as he or she is transferred from one team to another. The command/ dispatch center is the primary command and control device used for the response. It receives calls and dispatches teams to the scene, provides a communications link between supporting agencies and the director, keeps pertinent call data (times, mileages, etc.) and receives communications from and directs communications to the individual teams and personnel involved with the response. The command/dispatch center also ensures mutual aid is available when and where it is needed. It is probably easier to understand the method by which the Zone Team plan works if we follow the call in progress within this discussion. It seems complicated at frrst, but when one realizes that it is merely a series of coordinated steps already outlined in the pre­ plan, it really is simple. Let's follow the response path as it happens.

The radio in the command center crackles and the dispatchers glance toward it. "We need a medical team to section 124, row six.! " the guard yells into his mike, trying to overcome the intense noise around him. The security/police dispatcher tries to elicit any further information, but there is none. He gives this to the medical dispatcher who, in turn, decides which primary team is responsible/or this area. He keys his mike and says, "Team 3 respond. section 124, row six. unknown medical problem." Team 3 acknowledges and makes their way toward the scene. The dispatcher again keys his mike and sends Rove 2 to the nearest stagmg area to await the primary team's report.

Hearing these transmissions, the designated assistant begins moving in the direction of the call (elapsed time: 45 seconds). The passage above represents the access and dispatch stages of the response chain. The primary (BLS) team moves to the scene itself while the Rove (ALS) team moves to the nearest designated staging area to await the transport decision. There is no need for the rove team to go to the scene itself until their services are deemed necessary... why haul two hundred pounds of equipment up twenty flights of stairs for a hangnail? This is one of the ways in which this plan maximizes ALS resources.

Team 3 arrives at the patient's location, guided by the security guard stationed at the tunnel entrance (elapsed time: 1 minute, 50 seconds). They see that CPR is being performed by two men, one ofwhom informs them that he is a registered nurse and this woman is pulseless and had been downjust afew seconds before they intervened. Rove 2 arrives at the staging area and waits. The team leader directs his assistants to take over CPR, advises dispatch that this is a working code and requests the rove team move up with the backboardfor rapid extrication. Two rove team members take the board and move rapidly to the scene while the third member prepares the ALS equipment to receive the patient. Dispatch determines which transport team is responsible for that zone and sends them to the nearest gate. The security/police dispatcher sends four security guards to the staging area to provide safe transit for the patient. The patient is placed on the backboard and the medical teams begin their ascent to the tunnel entrance (elapsed time: 3 minutes, 15 seconds). At this point, the call has entered the extrication phase. The patient is moved on the backboard (with CPR in progress) to the staging area. There, advanced life support procedures will be done in a safe and organized atmosphere. The flow of this call will be overseen by the designated assistant to ensure the response path is uninterrupted and that every chance for success is given.

The adjacent primary teams (Teams 2 and 4) move a little bit tOl-l'ards each other to ease access to what has become their expanded areas ~f responsibility, according to the briefing they all had that morning. The command center alerts Transport Team 1 to assume responsibility for Rove ~ 's zone until they clear from the call (elapsed time: 3 minutes, 20 seconds). We see here the intrinsic back up provided by the Zone Team plan. There is always some way to fill the gaps in coverage caused by a team or teams engaged with a call. The adjacent primary teams split the responding team's area and cover it while they are busy. The transport team designated by dispatch covers the responding rove team's zone until they clear from the call. and then will assume responsibility for the busy transport team's transport zone until they return from the hospital. Admittedly, it sounds complicated, but when one thinks about it as teams just moving up a notch in the chain for a bit, it becomes less cloudy. Schematically, it might be represented as follows (for a very simple CCZ):

Director

Designated Assistant

Command/Dispatch Center

Primary Teams 1,2 and 3

Primary Teams 4, 5 and 6

By tracing the solid lines of the above chart, one can see the hierarchy along which the chain of command flows. The dashed lines represent mutual aid options (i.e. Transport 1 can back up Transport 2 or either of the rove teams). It should be stressed, however, that mutual aid can only flow "down" or "across." A BLS team cannot provide mutual aid to an ALS team, but an ALS team can provide aid to a BLS team. BLS teams may provide aid to other BLS teams (such as covering their area until the busy team clears).

The designated assistant directs the security officers to clear a path for the patient and the teams to the staging area. The patient is placed on the cot and the first three shocks are delivered (elapsed time: 4 minutes, 55 seconds). As ALS interventions are begun. the rove team leader releases all but one of Team 3 's members, and they return to their zone, releasing teams 2 and 4. The high-pitched beep ofthe ambulance's back up alarm signals the arrival ofthe transport team (elapsed time: 5 minutes 25 seconds) and stabilization measures are completed. The rove team begins to move the patient to the transport point and transfers care to the ambulance's crew. The designated assistant takes the woman 's husband to the front seat and assures him that all that can be done is being done. Final stabilization takes place in the back ofthe truck and the doors close. The siren chirps to clear gawkers from the sidewalk and the ambulance begins its way towards the hospital (elapsed time: 7 minutes, 50 seconds). The elapsed time for this call from receipt of the call to beginning transport was less than eight minutes--not at all unrealistic for this situation. If all the teams know their jobs

and responsibilities, the response path will not be like walking down an unfamiliar trail, but like following road signs to the terminus of the call. Actual call data were analyzed for medical responses both prior to and after inception of the Zone Team plan. This data was broken down into response time, time on scene and total time of call (dispatch to delivery to the ambulance). The data for mass event call times prior to the Zone Team plan are as follows: Average Response Time Average Time on Scene Average Total Call Time After development

3.25 minutes 11.08 minutes 14.08 minutes.

of the Zone Team plan, mass event call times were:

Average Response Time Average Time on Scene Average Total Call Time

0.92 minutes 6.85 minutes 7.77 minutes.

To test the validity of the changes observed, a statistical method called the Match­ Paired T Test was calculated along with the confidence factor (P). Our results were a calculated T of3.73, p=0.07. These results show two important points: 1) the changes observed were large enough to mean something and, 2) that there was a 93% chance that these changes were due to the Zone Team plan, not just dumb luck. How will this plan affect the mass event EMS coverage arena? That has yet to be seen. The only data available for the Zone Team plan is for Marshall University sporting events and other mass events for the years 1996 and 1997. It would be very interesting to see if this plan causes significant changes in response times for other organizations. It is oW' belief that this plan can be adapted and used by other services for their mass event responses with favorable results. We have had great success adapting this plan to our varied mass event situations. We use it for the football, basketball, and other large-draw sporting events, for the annual West Virginia State Special Olympics Summer Games held on our campus, as well as a couple of large crowds drawn by notable political figures who've visited recently. The Zone Team plan hasn't let us down yet. With appropriate command and controL thorough briefings of personnel and good pre planning, this plan serves extremely well. Undoubtedly, it can be adapted and used by other organizations with equal success. Simply, it is a web of intrinsic mutual aid plans paired with a hierarchy along which the call flows. The presence of a defmable method to provide coverage cuts down on confusion among providers and increases confidence with event sponsors that their event will not be marred by tragedy. We have seen in the past that medical teams get bogged down all too easily when the situation involves high participant density and multitudes of people. This plan is merely a single effort designed to minimize this risk.