First responders are often deployed to unique operating environments, which include large-scale special events with many participants and spectators: street festivals; road races or marathons; concerts; and sporting events. These environments require leadership to take a forward-thinking posture in the planning process to develop strategy. It also relies on front-line personnel to execute tactics that vary from day-to-day operations.
Emergency Medical Services (EMS) is called to respond to an increasing number of incidents that occur within unique operating environments (UOEs). These environments have the potential to tax available resources or challenge standard methods for response operations.
Considering the landscape at UOEs, for most jurisdictions, the population surge to a condensed area creates the greatest challenge. With any mass gathering, EMS responds to all of the usual call types, both medical and traumatic in nature, including: allergic reactions; cardiac and chest pain; respiratory; trips and falls; heat-related emergencies; or overdoses. However, these UOEs pose the challenge of seeing these calls at a much higher volume. Normal deployment models do not account for the surge of people into an area usually covered by a single response unit, such as college and professional sporting events or concerts. Although there are defined times for the actual event, spectators tend to arrive many hours earlier to partake in tailgating activities. This expands the footprint of the event beyond the confines and comforts of the walls of the stadium. Stadiums can hold 60,000-100,000 people and that number soars with those who just come for the tailgating to enjoy the environment. Hazards such as hot grills, the combination of moving vehicles with intoxicated pedestrians, and environmental exposures could increase call volume.
Street festivals pose similar challenges to the sporting events and concerts. A significant difference exists: these events typically occur on roadways that are traditionally open to moving traffic. The road closures inherently challenge EMS response, both within the event and to the nearby buildings for routine requests for service. It also increases vehicular traffic to nearby streets, thus complicating response. Further, the surge of population tends to sprawl beyond the confines of the event footprint to area parking decks or parking lots, area businesses, and nearby roadways and sidewalks.
When considering a road race or marathon, EMS must take into account the sprawling nature of the event. Although the route is defined, a single event crew cannot possibly cover the entire route effectively. This is particularly true of a marathon or triathlon, which may sprawl over several jurisdictions. This requires coordinated planning with several different stakeholders. Road closures and changing detours complicate response by potentially closing typically used routes to calls outside of the event. It is important to communicate with race coordinators to determine if participants’ medical history and contact information will be on the back of their race bibs in the event the runner is incapacitated. If not, knowing who will have the participant emergency contact information is critical.
With any of these situations, a mass casualty or multi-patient incident is increased just by the inherent fact that there are more people in a smaller and compact area. In addition to all of the above challenges, those responsible for planning must consider a nefarious act at any of these venues or footprints. Threats using small arms, edged weapons, improvised explosive devices, or vehicle ramming remain just a few things to think about when evaluating the “what ifs” for low-frequency, high-consequence incidents.
A Unique Approach for a Unique Operating Environment
In order to best approach the management of a UOE, a unique outlook and approach are needed. First and foremost, each EMS system must develop a way to communicate with community leaders and planners from a variety of disciplines, particularly with those responsible for organizing events. If not part of the permitting approval process, it is important to communicate with those that are to ensure cooperation with approved events and perhaps have input on potential impacts prior to the event’s approval. Without the awareness of an event happening and not having a seat at the planning table, EMS considerations may be lacking.
Internally, it is important to establish resources on hand to manage the challenges the event presents. These could include ambulances and personnel, but also specialized services and units trained to deploy to UOEs such as bike teams, foot teams, carts, command assets, and command posts. Each of these assets has its own advantage. For example, a bike team is able to reach much further in a quicker time frame than a team on foot and typically with greater ease and more safely than an ambulance crew. In more crowd-dense areas, bikes may not be able to navigate the crowds, leaving a foot team as the best option. In both cases, they are limited with transport capabilities to a rendezvous point with an ambulance, so the use of carts or a utility vehicle modified with a stretcher mount or space for a supine transport on a backboard or other similar device and/or seating would be a better option. A combination of these resources improves capabilities. It is beneficial to work smarter, not harder!
It is also important to consider allied partners, “Do the hospitals in your area have response teams or assets that may be used for triage or treatment, cooling stations, or workforce multipliers in these environments?” If so, with daily interaction with these hospitals, this partnership would likely be seamless.
EMS systems must have a way to “flip the switch” for a modified operations plan when working with these UOEs. When there is an event that is either resource dependent or results in a mass casualty or multi-patient incident, the ability to mobilize an appropriate response becomes necessary. Some ideas to incorporate into this plan include:
- Staging areas: Evaluating possible staging areas able to accommodate all responding disciplines and apparatus. This could be a regionalized concept so the jurisdiction has some predetermined areas and these may also be used during normal operations. Remember, a desired parking lot differs in usability on weekdays to weeknights and weekend days to weekend nights. It is important to assess these options for various operational periods.
- The incident within the event: There needs to be some foresight to determine how incoming units will integrate into an already existing organizational structure. Regardless, whether treating it as an incident within the event, to build a new incident command structure, or using the existing structure to build divisions or groups into the existing command structure, the threshold for a mass casualty or multi-patient incident should be considered to determine when to execute the plan.
- System coordination: Whether operating a single department or multiple departments in a single jurisdiction or across several jurisdictions, it is important to establish a person who can step back and take on the roll of “air traffic controller.” Ideally, if possible, this could be someone who takes a position at the dispatch center helping to make decisions about changes to deployment. It is a strategic position and should be a person with the knowledge and authority to alter responses. This modification allows for the following: vetting and altering traditionally multi-unit responses to fewer or even single units during this time period; determining which calls can be held for a period of time; or calling and managing other mutual aid. By removing this person from the mix of the other operations, they are able to objectively assist with managing all of the other needs and requests for service, modifying response as appropriate. Ideally, as guidelines, modified operations plans are developed ahead of time, such as for severe weather, time when resources are depleted, or when an incident occurs at a UOE.
- Transportation decisions: Having transportation plans ahead of time allows for less just-in-time decision making for crews on the scene in the heat of the moment. This determination requires early communication with the emergency departments about a multi-patient response. If possible, it is beneficial to disburse patients to several facilities instead of overloading a single location. Working on relationships early with area mass transit bus options or local school district bus assets are good options to move many people with few ambulances.
Building the Ranks
The initial groundwork at an incident within a UOE must be laid early on, sometimes before senior leadership and command staff arrives on location to build out the incident command system. With this in mind, it is just as important to build the capabilities of front-line personnel as it is to continue to develop the leadership’s incident command capabilities. Building the team through tabletop or scenario-based training not only improves comfort of incident management at UOEs, mass casualties, and multi-patient incidents, but also utilizes sharing of ideas and collaboration to support best practices. This further allows for the reinforcement, familiarization, and review of standard operating guidelines, protocols, and agency policies.
Additionally, specialized training should be delivered to those who serve on special operations or specialized service units operating in these UOEs. The need to incorporate unit-specific training for bike teams, venue-specific teams, or special event units should incorporate the protocols used in routine operations coupled with the challenges faced in these environments. The goal is for personnel to sharpen their skills for unique delivery.
Preparing for Future Events
The reality is communities will continue to host events and street festivals, performers will continue to put on concerts for fans, and sports teams will continue to compete. EMS should support these UOEs within the communities served and, as a discipline bridging the public safety and healthcare industries, EMS has a responsibility to deliver services in these environments. Of course, while it is easier to have a grasp on an event before a major incident occurs within that event, through enhanced awareness and planning – and by modifying a few plans and delivering training for UOEs – personnel become increasingly comfortable and prepared to operate within these environments, either as deployed and dedicated assets or when responding to a 911 call and arriving first without a pre-deployed cache of assets and personnel.
Seth J. Komansky, MS, NRP, is deputy director and chief of operations for the Wake County Department of Emergency Medical Services (EMS) in Raleigh, North Carolina. He is responsible for the day-to-day operational function of Wake County EMS response units and personnel. He supports the paramedics, EMS techs, field training officers, and district chiefs. He is also responsible for special operations, which includes community special event support, EMS Honor Guard, bike team, hazardous materials medical response, and tactical paramedic program. Additionally, he manages the Wake County EMS Medical Intelligence Unit and serves as the statewide EMS field liaison officer coordinator at the N.C. Information Sharing and Analysis Center, North Carolina’s state fusion center based at the N.C. State Bureau of Investigation. He has a Master of Science in homeland security management from the Homeland Security and Terrorism Institute at Long Island University.