Mass gathering events that involve special populations have challenges that require unique medical planning considerations. There are a number of factors that a medical team must anticipate and prepare for prior to the event. In the words of the athlete Jackie Joyner-Kersee, “It is better to look ahead and prepare than to look back and regret.” Thus, comprehensive medical planning must consider the special needs of athletes, spectators, any personnel involved, and the community at large to ensure both safety and efficient care of those in need. The medical team also must have knowledge about large-scale emergency planning in order to execute skills beyond the medical tent. Excellent medical planning and coordination enable the medical team to be psychologically, technically, and physically ready to care for athletes in a sporting domain. This article outlines key considerations to aid in preparing for a large-scale sporting event such as the 2015 Special Olympics World Games in Los Angeles, being held this summer.
The key to a successful mass event is in the planning, preparation, and communication. There needs to be communication in advance between medical and nonmedical personnel, with a point person (i.e., medical director) or team to coordinate the various entities that are involved. The most effective form of communication is verbal, either in person or via telephone, but all communications also should be confirmed in writing to minimize confusion. Having a prewritten protocol for emergencies in an outline or flow sheet format that is distributed to all groups involved prior to the event is the best way to ensure that unexpected or undesired circumstances are handled efficiently and safely.
Nonmedical personnel are essential for most mass events. Local law enforcement and the fire department should be aware of the event dates and times, including any preevent setup times. Road closures and traffic diversion, especially in a metropolitan location such as Los Angeles, can pose challenges for emergency vehicles to access the athletes and provide timely transport to medical care. Maps with planned road closures and emergency vehicle routes should be part of the emergency action plan. These routes also should clearly be marked to ensure that the general population does not inadvertently interfere. Designated parking areas also should be clearly marked on the maps. In the case of a large international event, these signs should be written in clear English, the host country’s native language, if applicable, and any other required by the organizing body. For the Special Olympics World Games, the official languages are Arabic, English, French, Mandarin, Russian, and Spanish.
On the day of the event, real-time communication can be done by two-way radio or cellular phone. If the latter is the anticipated mode of communication, a list of phone numbers should be provided and adequate cellular reception should be confirmed prior to the event, including, but not limited to, inside arenas and in remote areas of outdoor events. However, even with adequate cell phone reception, backup portable two-way radios should be accessible, in addition to portable antennas for extended reception. The medical director, head of law enforcement, head of the fire department, and local site directors should all have access to the portable two-way radios. The radios should be tested and confirmed to be functional within the range of the longest distance event. In the case of multicenter events such as with the Special Olympics World Games, there should be regional leads that can directly report to the medical director at a designated central command center if needed.
The medical director also should ensure that an open line of communication exists between local area hospital emergency room staff and event staff. There should be event staff designated as hospital liaisons to direct and coordinate any patients that need to be taken in for hospital-level care. All local hospitals should be notified 2 to 3 months in advance so that they can ensure that adequate staffing is in place. They also should be prepared to call in additional staff as needed in the event of mass casualty. The address and directions of the nearest level I, II, and III trauma centers should be prepared in a single-page sheet to distribute to family members, coaches, trainers, or athletes as needed.
Other communication concerns that are specific to the Special Olympics World Games include intellectual disability and age of participants. These two factors are most pertinent when the need to obtain consent or dispense medical information arises. For the Special Olympics World Games, having family and coaches that know the athletes well, as well as interpreters, is critical. Interpreters will be available through guest services in all of the official languages. Ensuring a direct line of contact with interpreters who are skilled in medical language is critical. Abbreviated medical information and language spoken also may be listed on an athlete’s identification such as wristbands or the backside of bib numbers. This may aid the medical first responders when caring for an athlete.
In the event of a mass casualty disaster, there should be a clear chain of command and escalation policy. Mass casualty includes any incident in which the needs of the health care team are exceeded by its resources, often due to chemical, biological, nuclear, or explosive etiologies. The priority of care in this situation is protecting team members, protecting the public, protecting the patients, and then protecting the environment. Cooperation with law enforcement personnel and recognizing that medical care is no longer the first priority are critical. Law enforcement becomes the de facto top of the command chain to establish safety for volunteers, general public, and athletes.
Even after a safe zone is established by law enforcement, recognizing an individual’s scene safety should still be the first step. Hazardous materials, structural collapse, toxin exposure, fire, snipers, and contaminated victims are among some of the risks that may be present in a mass casualty event. Once a general and personal safe zone is established, medical triage can be done safely and efficiently. Every on-site medical facility should have a lead physician who can coordinate triaging patients to the appropriate level of care. Any volunteers or medical staff at each site should know to report the status of their patient to the lead physician. If a physician is not available at a site, then a registered nurse should be in charge of triage. Only the most pertinent information needed to quickly triage patients should be communicated, such as respiratory status, perfusion, and mental status. This can be used to group patients into levels of care using color-coded triage tags (red for critical patients with a chance for survival, yellow for patients who need care but likely will not decompensate if care is delayed, green for minimal nonurgent injuries, and black for imminent death). This information can then be communicated to emergency medical services (EMS) and to the respective hospital liaisons in an efficient and timely manner. In this scenario, the EMS will be communicating directly with the hospitals, so the hospital liaisons can assume the role of coordinating transportation out of the on-site medical facility and informing family members about where the patient is being taken. There should be secondary hospital liaisons in place to account for the increased demand. Law enforcement and fire department personnel also should be on standby for traffic control and crowd control.
The primary concern of the sports medicine team at a sporting venue is to ensure the safety of the athlete. Consideration is taken for the number and distribution of participants and spectators. Also, the type and location of the event dictate specific needs of equipment and immediate response and transport. The level of injury risk varies depending on the inherent risk of the event, underlying medical or intellectual conditions of the athletes, the number of athletes involved, and the location and type of venue involved.
Events may be classified into collision, contact, limited contact, and noncontact sports. Collision sports may include physical contact with other competitors or with inanimate objects (e.g., the ground) with great force, while contact sports involve routine physical contact with less force than that in collision sports. Collision sports of the Special Olympics World Games, such as judo, gymnastics, and equestrian carry a higher inherent risk of serious or life-threatening injuries. In addition to the common musculoskeletal injuries incurred in the collision/contact sports (judo, soccer, basketball, and handball), eye injury and cervical spine trauma can be seen. Likewise, there is a risk of falls from height in gymnastics and equestrian, so cervical spine equipment should be available. An errant projectile from any of the sports can cause great injury. It is recommended that each site have ability to provide basic wound care, suturing, and eye protection. Other classes of events such as cycling and powerlifting carry a higher risk of serious injury. These events may benefit from on-site physicians and medical staff trained in basic trauma life support and/or ambulances in anticipation of more serious injury.
Minor injuries (abrasions, contusions, blisters, etc.) can occur in any event. While the majority of medical care in mass participation events consists of minor injuries, the sports medicine team must prepare for serious or life-threatening events and mass casualty that may require activation of an emergency action or incident command plan. Each venue is different and presents unique challenges to the surveillance of and access to athletes. Strategic placement of trained staff in highly visible aid stations will assist in timely care by on-site providers. Trained providers can include physicians, chiropractors, nurses, certified athletic trainers, physical therapists, and medical assistants. Events with higher inherent risk for injury (collision or contact sports) may benefit from on-site sports medicine physicians with mass event experience or physicians trained in basic trauma life support and/or ambulances. In addition, uniformed law enforcement and security may deter potential terrorist plots and aid in public safety. Nonmedical volunteers also may assist in crowd control and general information.
The 2015 Special Olympics World Games in Los Angeles will include indoor events like basketball and gymnastics. Indoor and traditional outdoor sporting venues often have limited access to allow for ticket sales, help manage crowds, and allow for tighter security. However, this limited access also can pose a problem to the emergency response team. Each venue must be surveyed to find the most efficient route for emergency personnel to reach the injured athlete. The sports medicine team must anticipate road closures (from marathon or cycling events) and access to private pathways when mapping routes for the emergency response vehicles. Proximity and capacities of local emergency departments should be studied for each venue.
Aquatic sports including swimming, sailing, and kayaking all have unique care considerations. There are five aquatic class events, but only one class, the class with the standard pool event, is held in a controlled swim stadium. While it is commonly thought that experienced swimmers should not drown, it is a well-documented occurrence, and vigilance of lifeguards is required. The other aquatics events (sailing, open-water swim/triathlon, kayaking, and sailing) are in open-water venues, which, along with the risk of drowning, draw attention to cervical spine trauma from wave navigation which could be a higher risk with a special needs athlete. Thus, backboards, motorized water rescue vehicles, an adequate number of lifeguards, and standby dive teams are important. Additionally, the open-water swim venue can pose challenges to the timely identification of, and intervention for, an ailing athlete. Availability of watercraft and specialty personnel (e.g., lifeguards) will be crucial to access and transport athletes. Adequate communication between care providers and the medical director will help dictate whether an athlete needs on-site treatment, transport to nearby medical tent, or activation of an emergency action plan.
The outdoor events that are held in a public space require special consideration for access to athletes, crowd control, and ingress/egress of medical personnel and transports. This is especially important along event courses (triathlon, half-marathon, cycling) where a dedicated roadway for medical responder traffic can play a critical role. Communication and coordination with local EMS, fire, and police are essential. It is often useful to have medical personnel actively monitoring the course both as responders and communicators to the main medical tent and central command of any incoming athletes. The outdoor events also are the longest events. Issues involving hydration may arise, and the ability to assess electrolytes in the field would be prudent. Providers should be educated on the different types of athlete presentations at the end of an endurance event such as exercise-associated collapse to be distinguished from more concerning types of collapse that may occur at other times. Given the nature of endurance events, dermatologic issues often arise. Many event medical tents have found it useful to have a quick access station dedicated solely to dermatologic issues such as blisters and minor abrasions.
Risk of the elements holds true for all events that are held outdoors and not in a controlled environment. As more skin is exposed to the elements, heat illness, dehydration, sunburn, and foot burn are also of concern. Outdoor events that cover distance (cycling and distance running) may require several aid stations along the race route or roving vehicles to provide adequate surveillance of athletes. Outdoor venues including beach volleyball, bocce, equestrian, and golf may be at particular risk for the elements. Usually in summer, heat illness is the primary culprit, although one cannot discount the possibility for rain and lightning that may greatly increase the risk of injury from slipping or necessitate delaying an event. Both oral and rectal thermometers as well as an ice bath should be available, in addition to the ability to monitor the heat index with a wet bulb globe either by digital or standard measurement. On very hot days, the spectator risk is just as much of a concern. Special areas should be provided for element protection, and adequate public water should be made available. Considering the 500,000 expected spectators to attend, first-aid stations and information about where to find health care for spectators are useful.
For all venues, the sports medicine team also must consider the needs of the spectators and risk of mass injury due to accidents or intentional acts. The potential for terrorist acts at mass participation sporting events has required further consideration since the Boston Marathon bombings last April 2013. The cooperation of venue security, local law enforcement, and fire departments will be crucial for surveillance, communication, and prevention of any terror threats. Response to an act of terror will require activation of the incident command system, outlined earlier in this article.
Weather risks including environmental heat, lightning, earthquakes, or flooding also may pose medical planning challenges. Frequent meteorological reports can help the sports medicine team anticipate high-risk venues. Emergency exits must be mapped, and an evacuation plan must be created for each venue in the event of a mass casualty incident or inclement weather. In case of extreme heat or lightning, a safe area must be designated for athlete and spectator protection. Water stations and cool misters can help prevent or reduce heat illness in athletes, while spectator safety can be enhanced by increasing public awareness through announcements and education at the venues.
Poor air quality from smog and environmental allergens also may pose a risk to athletes and spectators. Since 1995, California law has prohibited smoking in many enclosed public spaces. However, air pollution from automobile emissions and wildfires may contribute to poor air quality. The Special Olympics World Games will occur in late July through early August in Los Angeles, when pollen, dust mite, and pollution levels can peak. This combination can exacerbate symptoms in athletes and spectators with underlying allergic, asthmatic, or chronic pulmonary disease.
Other environmental concerns include the quality of drinking water and local food products. The involvement of local and regional environmental health officials is needed for water testing, sanitation services, and solid waste disposal. Different venues will utilize multiple food service vendors. Food vendors who are not permitted may be present in the vicinities of event venues. Public health teams are needed for regulation of food vendors, while environmental health teams are needed for detection and management of any outbreaks of food-borne illness or communicable diseases.
Volunteering for mass gathering athletic events is a gratifying and enjoyable experience. Despite the best planning, accidents occur. Organizers of the athletic event need to recruit experienced medical personnel and carefully establish contingency plans. The medical team at the 2015 Special Olympics World Games will comprise 30,000 volunteers. Kaiser Permanente’s Sports Medicine physicians, various local physicians, nurses, and paramedics supported by volunteer first-aid responders, will coordinate medical care. All medical volunteers are required to have basic life support and automated external defibrillator training. Previous studies have demonstrated that paramedics or nurses working under medical guidelines are as effective as physicians when working in urban areas. Volunteer physicians participating in the event range from foundation level to consultants. Physicians with the higher level of training who are seasoned in sports medicine mass event care will have more advanced roles. These lead physicians also will be trained in advanced cardiovascular life support or basic trauma life support. In addition to medical providers and first responders, high-risk sports are covered by on-site ambulance for immediate activation of the emergency plan.
A written Medical Volunteer Manual designed by an experienced medical committee guides medical volunteers. The manual is designed as simple, to-the-point guidelines to ensure consistency of care from providers of diverse backgrounds and optimize athlete safety. The guidelines are developed for each injury or medical illness, include escalation procedures, and are consistent with local EMS protocols. All volunteers will be given a Medical Volunteer handbook containing copies of the Medical Volunteer Manual. An electronic version also may be made available to offer a green option. Medical volunteers are required to attend a live orientation and education seminar in June 2015 in addition to a general volunteer orientation. There will be a series of required Web-based modules (Web-Ex) available for the medical volunteers who are unable to be present at the live meeting. In addition to medical guidelines, the manual and training sessions will have information about safety systems that are in place to reduce injuries to volunteers, including how to appropriately use personal protective equipment, how to safely evaluate an athlete, and who to report to in the event of a volunteer injury.
In order to ensure the safety and efficient care of all athletes, their support staff, all personnel involved with the 2015 Special Olympics World Games, and the community at large, it is paramount to have the necessary medical planning and preparedness to manage the mass participation event. By assessing relative risk at each sporting event and venue, coordinated medical coverage by teams of physicians, nurses, and ancillary staff will ensure timely response and appropriate treatment of the athletes. All medical personnel will be trained to work efficiently as a team, to learn escalation protocols, and to be familiar with communications and documentation.
In addition, coordination with local security, law enforcement, and fire departments will allow for a concerted effort in deploying emergency action plans in the event of hospital transfers, mass casualties, or evacuation due to weather or disasters. Hospitals located near each venue will be informed of all the dates and times of the events in order to forecast hospital staffing needs. In the spirit of the Special Olympics and as their motto resonates, “Let me win, but if I cannot win, let me be brave in the attempt.” Comprehensive medical planning will permit all the athletes to experience the joy of athletic competition in the safest environment possible. In the event of any injury or harm, each athlete will receive the highest quality of care in the most expeditious manner, may it be on the field of competition or immediately upon transfer and evaluation at the nearest hospital. In the event of any natural disasters such as inclement weather or mass casualty disasters, prepared and coordinated interdisciplinary emergency actions plans will be executed efficiently.
The authors declare no conflicts of interest and do not have any financial disclosures.