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 Primary Teams

1,2 and 3 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 3.25 minutes

Average Time on Scene 11.08 minutes
Average Total Call Time 14.08 minutes.

After development of the Zone Team plan, mass event call times were:
Average Response Time 0.92 minutes
Average Time on Scene 6.85 minutes
Average Total Call Time 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.