Andrew M. Milsten, MD, MS, FACEP

Medical care at mass gatherings has been an important and growing field of medicine. When large numbers of people gather for an event (concert, game, fair, etc.), more injuries occur than would be expected among a similar sized general population cohort.¹ Despite several proposed models, staffing for these events has been inexact and institution specific. It seems that allied health professionals, prehospital providers, and nurses are best suited to mass gathering work. But what about physicians? Are they really needed at these events? Why can't the medical staff just page an on-call physician if needed? For that matter, if most mass gathering care is considered "band-aid and aspirin,"¹ why not just have a bandage and analgesia machine in the lobby? In this article, I will review some of the literature on the subject and present a few descriptive statistics from the Raven's stadium experience.

As with most of the mass gathering literature, the information concerning physician need at these large events has been retrospective, and there are no random clinically controlled trials. It has been generally believed that on-scene physicians are useful for many reasons (outlined below). An editorial by Brunko pointed out an article by Gay, an early "rock doctor" in San Francisco. The physicians were helpful at these events in analyzing the crowds' "collective mood" and partially predicting the types and numbers of patients encountered.^{2, 3} Brunko's group tried to predict "collective mood" and though imprecise, found it to be useful (especially during the Papal visits). On-site physicians were especially helpful in decreasing transported patient volume as well as dealing with refusals of care.

Boyle retrospectively studied the United States Air Show and found emergency physicians played an integral role.⁴ Data was collected over a 10-year period (2,092 treated, medical usage rate (MUR) 8.45/10,000), and the experience was beneficial to all involved (including the ED residents). Physicians were involved in 50 cases (MUR 0.2/10,000) with 148 hospital transports (0.6/10,000) and 20 refusals of care (0.2/10,000). The physician's role was decreasing the local EMS/hospital burden, preplanning, resident education, and improving documentation. The issue of documentation has been important for medicolegal reasons, but also because the smaller, less organized events are often staffed by basic emergency medical technicians (EMTs), who invariably need more physician guidance than paramedics.

Parillo made a case for physician involvement in mass gatherings that also included some planning considerations. Physician involvement helps bring together the quality of care as nurses and prehospital providers "work under protocol with the knowledge that help is available immediately if needed."⁵ Other aspects in favor of having a physician presence include research, cost (many physicians volunteer their time or are paid much less than their normal "hourly" rate), fewer hospital transports, potential for serious trauma (auto racing), distance of travel to definitive care, public relations, and improved disaster response.

A recent study from California prospectively showed that on-site physicians reduce hospital transports by 89%.⁶ Physicians were needed for 48% of patient encounters, but direct physician care was needed in only 9% of cases. Nursing-level care required physician protocol 39% of the time. This study prospectively showed that physicians are involved in a significant portion of patient care, as well as instrumental in reducing EMS transports.

NAEMSP (National Association of EMS Physicians) produced a Mass Gathering Medical Director's position paper.⁷ Preplanning for an event will be crucial and developing a medical action plan can help accomplish this task. This booklet attempts to lay out essential and desirable aspects of a medical action plan, with the first being physician medical oversight.

University of Maryland Expresscare (through the Division of Emergency Medicine), a critical care ambulance transport service, provides medical coverage to the fans at Raven's stadium. In the function of medical director, I get to attend many games each season (which thrills my friends and family), but mostly work with the prehospital team on many levels. Four years of descriptive statistics are outlined in Table 1, and give another retrospective perspective on the usefulness of on-site physicians (statistical program: none; calculations: done on my calculator). The overall MUR was 7.17 with physicians involved in 20% of cases (MUR 1.54). Hospital bound transports occurred in 1.7% of cases (MUR 0.63), and unfortunately, direct transports from the stands as well as refusals of care are not accounted for on the data set. Nonetheless, physician input was required for a sizable number of patients.

There are a few negatives associated with having physicians at mass gatherings such as possible cost issues and scheduling conflicts; however, the negatives are greatly outweighed by the benefits (Table 2). Physicians are in integral part of the mass gathering medical team from start to finish.

Table 1: Four football seasons at Raven's stadium. These numbers only include National Football League (NFL) games and patients seen in the first aid stations (some patients are taken directly from the stands to the hospital). FA = first aid station. Physician requests = the number of times a physician is requested to see a patient in an FA (and occasionally in the stands). Attendance is cumulative for the year. The MUR (medical usage rate) is presented in each cell. MUR = FA patients (for example)/attendance x 10,000.

Table 2: Possible benefits of physician medical oversight at mass gathering events

References

1. Milsten A, Maguire BJ, Bissell RA, et al. Mass-Gathering Medical Care: A Review of the Literature. Prehospital and Disaster Medicine. 2003;17(3):32-45.
   
2. Brunko M. Emergency Physicians and Special Events. J Emerge Med. 1989;7:405-409.
   
3. Gay GR, Elsenbaumer R, Newmeyer JA. A dash of M.A.S.H. The Zep and the Dead: Head to Head. J Psychedelic Drugs. 1972;5:193-203.
   
4. Boyle MF, De Lorenzo RA, Garrison R. Physician Integration into Mass Gathering Medical Care. Prehospital and Disaster Medicine. 1993;8(2):165-168.
   
5. Parrillo SJ. Medical Care at Mass Gatherings: Considerations for Physician Involvement. Prehospital and Disaster Medicine. 1995;10(4):273-275.
   
6. Grange JT, Baumann GW, Vaezazizi R. On-site Physicians Reduce Ambulance Transports at Mass Gatherings. Prehosp Emerge Care. 2003;7(3):322-326.
   
7. Jaslow D, Yancy A, Milsten A. Mass Gathering Medical Care. National Association of EMS Physicians Standards and Clinical Practice Committee. Prehosp Emerg Care. 2000;4:359-360.