Mass Event Zone Planning

8/14/2019 Mass Event Zone Planning

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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 Services400 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 intheir 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 toresolve them. One area of concern to many EMS organizations is the best method to facilitate emergencymedical coverage to what we have called a Mass Event. Simply, a mass event is any gathering of peoplewhere either the numbers of people or the size of the response area taxes the public safety resources of theresponsible agency or agencies. The following discussion describes the problems and pitfalls common tomass event coverage from a prehospltal point ofview, two fairly common methods by which an EMS call ishandled in the mass event situation, and the relatively new method by which Marshall University EMSprovides emergency coverage in the mass event situations common to this organization.


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We open at a college championship football game in a medium-sizedAppalachiancity. The scene is one ofbarely controlled chaos, i fchaos is the correct word to describethe euphoria expressed by thirty-fIVe thousandfootballfans at their star player scoringthe tie breaking touchdown ofa hardfought game. The frenzy builds to a crescendo ofjoyful 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 aproductive one. Police and security officers strain to hear their radios while they watchthe 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 potentialfor problems with this many people presentfor their game. And in the middle ofit all--inthe midst of this mania--a sixty-two year old woman suddenly realizes she's in seriollstrouble.

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 hershe wouldn't survive another one i fshe didn 'tfollow his instructions and get herselffitagain. She had another, much milder problem two years ago after deciding she wasbetter and could live "f ree." She was home injust afew days, but swore she'd not let ithappen again. This is different, however. She's dizzy and tired, having trouble breathingand her chest feels as though there's a car parked on it. She leans on her husband ofthirty-six years and looks up at him, watches his face turn from greatjoy to intense fear,and sinks into unconsciousness.

What do we, as Emergency Medical Technicians, do about this? How do we bestprovide for the medical coverage necessary in such situations? Why must our response inthis case be different from our normal operating mode? The simplest answer that can begiven is simply time. The best medicine we can ever give to any patient we encounter istime; more precisely, the less time, the better. I f we can keep the elapsed time for theresponse to a minimum, we go a long way toward minimizing the patient's suffering andhopefully can prevent an untimely death. Few can argue with this statement.

To understand the importance of preplanning a response path during an eventsimilar to the one above, we must begin to understand the true uniquenessof this class ofresponse areas. These situations are known by several names: concerts, rallies, ball gamesand so on. In EMS circles, they are not often thought of as a definable situation, merely agathering of many potential patients. Many municipalities seem to regard these situationsmerely as a relocation of their patients to a more centralized area and may move anotherambulance or two to the vicinity. little thought seems to have been given to the idea thatthe event itself is an important situation that must be looked at from a slightly differentviewpoint. 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 onpublic safety resources because of: a) the number of people in attendance, b) the high ratioof attendees in a given area to public safety p e r s o n n e ~ and c) the size of the facility or areain which they are gathered produces a high density population. They may range in sizefrom a few hundred people participating in a Walk-a-Thon to the 1vfillion Man March inWashington, DC a few years ago to Woodstock n. These events present unique problems


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for the Emergency Medical Services provider not encountered during a "normal" call. Amajor problem is that the potential for injury and illness during the event increases simplydue to overcrowding, the emotional state of the attendees, the propensity for drink andrevelry, and the like. During a mass event, the EMS providers are likely to have to plytheir craft with an audience ofgawkers, of f duty medical professionals andparaprofessionals, and the media. All the while, the clock is ticking minutes of f the"golden sixty" and the ''platinum ten."

Every response plan to date seems to be very concerned with time. We see it onour run sheets, in the Emergency Department, the dispatch log sheets, and we have arunning cadence in our heads as we package and treat each patient. When we try toperform our duties in an extremely crowded, noisy and dangerous atmosphere, we simplycannot treat the patient as we normally would in their home. We must take into accountthe dangers associated with working in the masses. We must be vigilant for our own safetyand the patient's. We must be cautious when using advanced life support procedures (I'vepersonally witnessed on two occasions the defibrillation of an entire row of spectators onmetal bleachers!). We must also keep our eyes on the clock. It simply takes more time tomove a patient in a crowd. The more we dawdle, the faster they die!Several major problems must be addressed and overcome for a mass eventresponse plan to be effective. First and foremost is the lengthy response times common tothese situations. A method must be found by which providers can get to the patients morequickly and safely. Provider fatigue is a factor, especially in the large sports stadiumscornmon to universities and large cities. I f the EMTs must make their way up flight afterflight of steep stairs carrying all their equipment while fighting the crowd, package thepatient and extricate them back down those stairs to the ambulance, the likelihood ofbeinginjured 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 personneland lack of easily accessed telephones (excluding cell phones, of course). Command andcontrol of the response teams can provide either a solid foundation for the response or theweak link in the chain of events leading to the patient's death.

Frantically, her husband tries to awaken her with the ful l knowledge that ifhecan't get her to open her eyes, she'/I die. Panic-stricken, he gains the attention of theperson standing beside him (who didn' t notice the emergency because ofthe standingovation and the noise) and sends him for help. This messenger tries to move down thepacked row ofspectators to the aisle, where he hopes he'l lfind a security guard. Hebreaks into the open and looks toward the tunnel entrance to his section for the guards hesaw earlier that day. He sees one cheering with the crowdand runs up severalflights ofstairs to him. The woman's husband is oblivious to everyone around him as he begins toweep.

The example above is typical of the first stages of an emergency in any mass eventscenario. Bystanders recognize the situation exists and try to take action. The mostimportant 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 thechain of events from initial recognition to delivery of the patient to the EmergencyDepartment, as well as team recovery back to the event site. Recognizing the importance


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of each step in the call cycle is paramount to the effectiveness of the pre-plan and of theactual response.

The pre-plan starts where the call starts...initial recognitionof the emergency andrapid access to the medical teams there to provide coverage. We, as providers, cannotcontrol the occurrences, but we can assist the victims by making access to EM S as simpleand visible as possible. Every event official, from the ushers to the director,must be madeaware of the importance of rapid action in dispatching medical teams to the scene. Theyshould be made aware that official visibility will greatly decrease the time from onset of theillness or injury to the arrival of the medical team. A rapid response will assist in "'decreasing the morbidity/mortalityof patients, and this in tum will keep liability (andmaybe even insurance costs) to a minimum. This isone of the most important concepts ofmass event medicalcoverage and should not be taken lightly.

As an aside, the proliferation of cellular phones today poses a unique problemforthis situation. Calling 911 may actually increase the response time due to the addition ofseveral more steps in the response chain. I f the 911 dispatch center is not made aware ofthe method by which the event is covered and who is responsible, an ambulance fromoutside the mass event plan may be directed to the scene. In the time that it would take foran ambulance to respond, the patient may have been on his or her way to the hospital i f thecaller had simply spoken to security. Emergency dispatch centersneed to be made awareof the ev ent's intrinsic medical coverage so that they may refer the call to the event'scommand center for a more efficient response.

Once access to EM S has been gained, the focus of the response is on speed andefficiency. Prior to the event, EM S officials and rescue personnel need to go to the siteand develop their specific response plan. Each plan is unjque to the event and mustbedeveloped in the light of the unique variables associated with the event. These variablesinclude, but are not limited to, the physical size and layout of the site, the number ofparticipants expected, the number of providers available, the EM S resources that can beutilized, availability of mutual aid from outside EM S sources, etc. Pathways of movementfor th e initial response teams, ambulance supportand supporting agencies must berecognized and defined. An efficient method of intrinsic mutual aid must be developedshould the need arise. And lastly, an event protocol should be developed that takes intoaccount the unique structure of the response plan. Mapping the event site and providing awritten directive for the medical teams is also most helpful.

These authors will not attempt to provide a "unified theory of event coverage" thatis a catch-all for every situation. We will merely discuss the methods by which we covermass events at Marshall University and the surrounding area. From this discussion, wehope to stress the importance of pre-planning the coverage and demonstrate the method bywhich we've arrived at our current plan.

There seem to be two primary methods by which mass event coverage responsesare done. These are defined by these authors as the Unit Team method and the ZoneTeam method. Unit Team responses are those in which the responding medical team hascontrol of the patient from initial dispatch to the ambulance's arrival at the ED. They carryall necessary equipment to effect the response and maintain patient contact throughout thecall cycle. This is how EMS responses in the normal prehospital environment usuallywork. Tw o significant types of Unit Team response strategies are the Central Unit Teamand the Dispersed Unit Team strategies. The Central Unit Team strategy is most like


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''nonnal'' EMS in that all EMS resources and personnel are dispatched out of a singlestaging area. The Dispersed Unit Team strategy is one in which the individual teams areplaced in strategic locations and, with patient in tow, meet the ambulance at a designatedtransport point. Usually, with this last strategy, a "flying" equipment pool responds to thepatient location to provide bulky items to the team, so as to avoid an extremely largeequipment 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 thepatient/bystanders is less likely to be confused during transfer than i f there were more thanone team involved. The transporting crew goes to the scene itself and may be able to gainmore information as to the nature of the call than might be transmitted between two teams.Patient rapport is likely to be more solid than i f several teams are involved. Several majordisadvantages exist,' however, that in our opinion are less desirable than the advantagesgained. First, and possibly most important, is team fatigue. In many cases, the accessextrication distance and situation are long and difficult. Fatigue leads to judgment errorsand increases the likelihood of provider injury. Of these plans, the Central Unit Team planhas 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 toby providers and yields more solid patient rapport. The Dispersed Unit Team plan hasmuch shorter response times, but may yield high levels of provider fatigue as the teamsextricate the patient all the way to the waiting ambulance. Mutual aid during the call is asslow or slower and just as tiring as the initial response.

We have tried variations of these methods and found them inefficient for thereasons stated above (and others) and have attempted to develop a more efficient plan forour needs. Marshall University EMS provides coverage for several different mass eventscenarios during the year and we needed to develop a flexible plan that we could adapt toeach of these. Primarily, our concern has focused on the NCAA sporting events held atany of our major facilities during the school year. We have a medium sized basketballarena 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 ournonnal campus population, and we must be able to quickly and efficiently provide medicalresponse to everyone within our district.

MUEMS is a volunteer service, and as such, we may have more or less thenumbers of personnel required to provide effective coverage at an event using thepreviously-mentioned methods of coverage. We also maintain only one ambulance oncampus and have needed to develop a plan for mutual aid while that single vehicle isengaged on a call. To efficiently utilize our limited personnel and resources, we havedeveloped what we call the Zone Team method of coverage.The Zone Team plan is a tiered response plan that was developed by a fusion ofwartime military medical response methods, civilian EMS methods, and mass casualtyincident response plans. Simply put the response area is divided into Central CommandZones of coverage and there are teams ~ i t h i n those zones pre-positioned to affect animmediate 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 entityand possesses its own resources. Each CCZ should have its own command! dispatchcenter, but several may be able to function under a single command/dispatch center i f it isorganized well.


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Each CCZ is divided into major zones of response. Each zone has a single rovingAdvanced Life Support (ALS) team with all necessary equipment for the extrication of apatient from the scene (i.e. cot, stair chair, spine board, etc.) as well as for ALS-Ieveltreatment. These zones are further divided into primary response areas where Basic LifeSupport (BLS) teams are stationed. In many cases, the BLS teams are the initial point ofcontact for the access into the EMS system as they have such a high visibility within theirareas, yielding extremely short response times. The ALS teams are responsible for the

'rBLS teams in their zone and provide a basic level of command and control as well asmutual 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 treatedlike 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 pointsare established where the ambulance meets the patient. Each transport team is staffed andequipped the same as the ALS rove teams because they provide mutual aid to the roveteams while they are engaged with a call (in other words, dispatch will designate a transportteam to act as an ALS rove team until the original team clears from the call). Eachtransport zone has its own assigned ambulance that responds to transport patients to thehospital.

The command and control element consists of the director, a designated assistantand the command center. The director is responsible for all areas and actions within theCCZ. He usually refrains from direct patient contact, as his primary role is direction of theresponse (a traffic cop, i f you will). The designated assistant provides on scene commandsupport, direction and medical assistance i f necessary. He is the on scene eyes and ears forthe director and ensures the response chain moves as planned. He also may provide therapport link for the patient as he or she is transferred from one team to another. Thecommand/ dispatch center is the primary command and control device used for theresponse. It receives calls and dispatches teams to the scene, provides a communicationslink between supporting agencies and the director, keeps pertinent call data (times,mileages, etc.) and receives communications from and directs communications to theindividual teams and personnel involved with the response. The command/dispatch centeralso 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 worksi f we follow the call in progress within this discussion. It seems complicated at frrst, butwhen one realizes that it is merely a series of coordinated steps already outlined in the preplan, 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 toovercome the intense noise around him. The security/police dispatcher tries to elicit anyfurther information, but there is none. He gives this to the medical dispatcher who, inturn, 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 3acknowledges and makes their way toward the scene. The dispatcher again keys his mikeand sends Rove 2 to the nearest stagmg area to await the primary team's report.


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Hearing these transmissions, the designated assistant begins moving in the direction ofthe 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 tothe nearest designated staging area to await the transport decision. There is no need for therove team to go to the scene itself until their services are deemed necessary...why haul twohundred pounds of equipment up twenty flights of stairs for a hangnail? This is one of theways in which this plan maximizes ALS resources.

Team 3 arrives at the patient's location, guided by the security guard stationed atthe tunnel entrance (elapsed time: 1 minute, 50 seconds). They see that CPR is beingperformed by two men, one ofwhom informs them that he is a registered nurse and thiswoman is pulseless and had been downjust afew seconds before they intervened. Rove 2arrives at the staging area and waits. The team leader directs his assistants to take overCPR, advises dispatch that this is a working code and requests the rove team move upwith the backboardfor rapid extrication. Two rove team members take the board andmove rapidly to the scene while the third member prepares the ALS equipment to receivethe patient. Dispatch determines which transport team is responsible for that zone andsends them to the nearest gate. The security/police dispatcher sends four security guardsto the staging area to provide safe transit for the patient. The patient is placed on thebackboard 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 onthe backboard (with CPR in progress) to the staging area. There, advanced life supportprocedures will be done in a safe and organized atmosphere. The flow of this call will beoverseen by the designated assistant to ensure the response path is uninterrupted and thatevery chance for success is given.

The adjacent primary teams (Teams 2 and 4) move a little bit tOl-l'ards each otherto ease access to what has become their expanded areas ~ responsibility, according tothe briefing they all had that morning. The command center alerts Transport Team 1 toassume responsibility for Rove 's zone until they clear from the call (elapsed time: 3minutes, 20 seconds).

We see here the intrinsic back up provided by the Zone Team plan. There isalways some way to fill the gaps in coverage caused by a team or teams engaged with acall. The adjacent primary teams split the responding team's area and cover it while theyare busy. The transport team designated by dispatch covers the responding rove team'szone until they clear from the call. and then will assume responsibility for the busytransport team's transport zone until they return from the hospital. Admittedly, it soundscomplicated, but when one thinks about it as teams just moving up a notch in the chain fora bit, it becomes less cloudy. Schematically, it might be represented as follows (for a verysimple CCZ):


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Director

DesignatedAssistant

Command/DispatchCenter

Primary Teams Primary Teams1,2 and 3 4, 5 and 6

By tracing the solid lines of the above chart, one can see the hierarchy along whichthe chain of command flows. The dashed lines represent mutual aid options (i.e. Transport1 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 aidto an ALS team, but an ALS team can provide aid to a BLS team. BLS teams mayprovide 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 patientand the teams to the staging area. The patient is placed on the cot and the first threeshocks are delivered (elapsed time: 4 minutes, 55 seconds). As ALS interventions arebegun. the rove team leader releases all but one ofTeam 3 's members, and they return totheir zone, releasing teams 2 and 4. The high-pitched beep of the ambulance's back upalarm signals the arrival of the transport team (elapsed time: 5 minutes 25 seconds) andstabilization measures are completed. The rove team begins to move the patient to thetransport poin t and transfers care to the ambulance's crew. The designated assistanttakes the woman 's husband to the front seat and assures him that all that can be done isbeing done. Final stabilization takes place in the back of the truck and the doors close.The siren chirps to clear gawkers from the sidewalk and the ambulance begins its waytowards the hospital (elapsed time: 7 minutes, 50 seconds).

The elapsed time for this call from receipt of the call to beginning transport was lessthan eight minutes--not at all unrealistic for this situation. I f all the teams know their jobs


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and responsibilities, the response path will not be like walking down an unfamiliar trail, butlike following road signs to the terminus of the call. Actual call data were analyzed formedical responses both prior to and after inception of the Zone Team plan. This data wasbroken down into response time, time on scene and total time of call (dispatch to deliveryto the ambulance). The data for mass event call times prior to the Zone Team plan are asfollows:

Average Response Time 3.25 minutesAverage Time on Scene 11.08 minutesAverage Total Call Time 14.08 minutes.

After development of the Zone Team plan, mass event call times were:Average Response Time 0.92 minutesAverage Time on Scene 6.85 minutesAverage Total Call Time 7.77 minutes.

To test the validity of the changes observed, a statistical method called the MatchPaired T Test was calculated along with the confidence factor (P). Our results were acalculated T of3.73, p=0.07. These results show two important points: 1) the changesobserved were large enough to mean something and, 2) that there was a 93% chance thatthese changes were due to the Zone Team plan, not jus t dumb luck.

How will this plan affect the mass event EMS coverage arena? That has yet to beseen. The only data available for the Zone Team plan is for Marshall University sportingevents and other mass events for the years 1996 and 1997. It would be very interesting tosee i f this plan causes significant changes in response times for other organizations. It isoW' belief that this plan can be adapted and used by other services for their mass eventresponses with favorable results. We have had great success adapting this plan to ourvaried mass event situations. We use it for the football, basketball, and other large-drawsporting events, for the annual West Virginia State Special Olympics Summer Games heldon our campus, as well as a couple of large crowds drawn by notable political figureswho've visited recently. The Zone Team plan hasn't let us down yet.

With appropriate command and controL thorough briefings of personnel and goodpre planning, this plan serves extremely well. Undoubtedly, it can be adapted and used byother organizations with equal success. Simply, it is a web of intrinsic mutual aid planspaired with a hierarchy along which the call flows. The presence of a defmable method toprovide coverage cuts down on confusion among providers and increases confidence withevent sponsors that their event will not be marred by tragedy. We have seen in the pastthat medical teams get bogged down all too easily when the situation involves highparticipant density and multitudes of people. This plan is merely a single effort designed tominimize this risk.

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Mass Event Zone Planning