We put together these thoughts in 2014 after we had 4 years of experience in the event world. The overall themes are still valid, and we have refined how we execute our thesis to provide more value and expertise every year.
The following points of discussion will illuminate characteristics which should be considered when determining the amount and placement of medical (Usually evacuation & treatment) resources for an event which uses a venue consisting of technical and/or large geographic distances (typically > 0.5 SQ mile, or >1 mile loop distance). Since response time, level of care, available resources (providers, provider level, and equipment), and cost are interconnected, we have refrained from providing exact resource formulas in this document, and an experienced event medical system planner should assess each venue, guided by the below topics.
Each venue will have characteristics which shape the resource placement decisions. The scope of this document will conclude when a patient arrives at onsite care which can treat the injury, or a transport method (ambulance, helicopter, or POV) which can bring them to definitive care. Planning should determine if an onsite, dedicated transport (ground or air ambulance) is needed, and if one is not, what average and maximum enroute times are from the responding 911 agency are. (See Onsite Ambulance Considerations for a discussion).
As a starting point it is useful to gather from the promoter, stakeholders, and permitting bodies, the required and desired level of care for an event. They may be at odds and have political motivators, but we will address the question with standard practices and prudence.
- What response time is desired? 3-6 minutes may be typical in an urban 911 system, and 10-30 minutes is not unusual in rural communities. In general, attendees at professional events expect prompt attention when an injury occurs. High numbers of youth suggest lower response times, as do activities with a higher potential for severe injury such as motorsports, wheeled sports, and activities at height. The likelihood of negative publicity may also play a role in driving the desire of the event organizer to shorten response and evacuation times.
Because of the deletion of an ‘enroute’ time that an off-site ambulance would have, onsite medical staff will often be onscene quicker than typical 911 service. This allows us to realistically aim for 1-3 minute response times at small venues, and 10-30 minute response times at a large rural venue. Discuss with the event what attendees may expect, what is possible given the available budget and resources, and then begin planning resource types and deployments. A mud run on a ten mile course may have 10 minute response times, while a 50 mile trail run may reasonably have a 15-90 minute response time even with very specialized staff depending on how many are available and what terrain they need to cover to reach the furthest parts of the course.
In general, attendees will expect a response time that is faster than what the 911 system can provide. Without providing that during a typical incident load, there is little justification for the cost of onsite medical staff.
Level of Care
Depending on the EMS system of the surrounding community, a standard of care may exist that should be continued or exceeded at an event. At an event which has the resources, it is reasonable to steer them toward ALS care for the good of their attendees, and since that provider- whether acting alone or in a team- is more likely to optimally manage difficult scenarios because of their greater experience. At events where more providers are useful to shorten response times on a large venue, or meet budgets, EMTs and first responders may be reasonable. A primarily BLS staff with one ALS provider is technically an ALS System, and can provide a very high level of care if organized correctly, especially since most emergencies rely on BLS treatments and good assessment.
Venue Related Incident Mitigating and Compounding Factors
- Farthest Point Scenario- Where on the course could an incident happen which would have the longest response time? Despite the likelihood of an incident to occur, a response plan would be incomplete without accounting for the most difficult or longest point or segment of the venue/course where an incident response might be needed.
Even if a minor incident occurs, without good communication relays, just getting resources onsite to provide a scene size-up could be taxing to the system. If your event continues while incidents are in progress, as most do, it is wise to clarify an ingress plan for difficult points of the venue to resource groups (Task Forces) so the event’s medical system remains functioning.
If the chance of incident(s) occuring at difficult points is likely, this may augment the entire resource deployment. If it is acceptable to have a longer response time to that location, positioning a resource group near the location, but not in it, will allow part of the team to respond nearby (sparing resources and costs), and reduce the response time to the most difficult point.
If this Furthest Point Scenario occurs in a place where the response time is orders of magnitude more than the venue average, tiered resource arrival is reasonable. If high level resources such as ALS providers, evacuation equipment, and technical personnel are scarce (Or the event as a whole has a small incident load, suggesting less resources), those resources should be placed within the bell curve of likely incident locations.
If a location which is difficult to access, evacuate from, and highly likely to have incidents occur there, that foreseen danger should have a dedicated resource group available, be deleted from the venue, or safety increasing measures (speed limits, greater communications, signage, terrain augmentation) should be applied.
- High Likelihood Locations- Any portions of a venue which are predicted to be more dangerous than average (Which have a high number of incidents and/or an incident will likely be severe if it occurs) should be identified. Those locations should be mitigated with injury prevention measures (speed limits, greater communications, signage, terrain augmentation) and/or have resources nearby and capable of managing a high incident/acuity load without under-resourcing the event’s medical system.
Attention should be paid to egress routes. If frequent patient evacuation by vehicle, litter, etc. is expected on a race course, effort should be toward not disrupting the event by:
- Most desirable: Off-course evacuation. (Evaluate vehicle/litter capabilities, ground conditions, and time to definitive destination).
- Less desireable: On-course in direction of traffic (Consider apparatus warning devices, pre-start encounter directions for participants, route entrapment, route finding).
- Least desireable: On-course evacuation against direction of traffic. May be the shortest distance or least time on course, but most disruptive while on course. (Consider apparatus warning devices, pre-start encounter directions for participants, route entrapment, route finding, course stoppage plan in extreme incidents)
- Concurrent Incident Possibility- Will one incident resolve before another begins? In a short-course competition, such as gated racing or when one or two participants are competing at a time, the likelihood of other competitors becoming injured is very low. This means it is reasonable to have a medical system capable of only attending on one incident, while at a competitive event that continues during injuries, such as a trail run or mountain bike race, the medical system should be capable of addressing multiple simultaneous incidents. Keep in mind there may be small (A slalom racer with a broken leg) and large (A crash during a road cycling race with four patients) incidents which stop competitions, so an event without the possibility of concurrent incidents may have more than one patient.
If the event has a likelihood of concurrent high-acuity incidents, or if the likelihood is low but a delayed response (Whether arrival, treatment, and/or evacuation should be defined by you and stakeholders) to concurrent incidents is undesirable, the medical system should have sufficient resources to conclude incidents at the rate they occur.
- Response and Evacuation methods- As venue/course distances increase, the speed providers move should increase, or the frequency of their deployment should increase. In general, the response group’s enroute mode will be appropriate for the venue if it matches or exceeds the mode being used by participants. For example providers on foot or bicycle are appropriate for a trail-run. An increased distance trail-run suggests bicycles, motorcycles, or vehicles, depending on terrain. For a mountain bike ride or race, providers on bikes, motorcycles, or vehicles would be a good match for the terrain and distances encountered. The distance between resource groups would likely be a poor match for providers on foot.
Courses with lengthy evacuation times (Typically greater than 30 minutes for non wilderness specialty personnel) should be evaluated for multiple evacuation destinations. The presence for landing zones for helicopters and roads accessible by local agency ground ambulances should be noted. Shorter evacuation durations result in resource groups returning to service faster and lower times to definitive care.
- Onsite Definitive Care- The ability to conclude incidents onsite has many benefits including:
- Decreasing patient load on community healthcare resources.
- Increased customer satisfaction for attendees.
- Definitive care for some injuries, reducing cost-induced litigation.
- Early recognition of serious illness and treatment before the issue becomes life-threatening.
- Continuance of activity for participants.
At first glance it might seem providing the personnel and equipment to definitively care for as many incidents as possible would be an added expense and hassle for the client. On the contrary- being able to treat hypoglycemia, asthma, abrasions, strains and bruises, dehydration etc., can prevent the evacuation of a patient who would become non-ambulatory or require transport to an ED/urgent care by ambulance or Personal Vehicle. Providing care so attendees can return to the venue or leave under their own power decreases resource-intensive responses from local 911 services, which has the following benefits:
- Less disruption to the ‘look and feel’ of the event, by discretely treating most injuries without an ambulance.
- When a 911 ambulance is needed, we can hand off the patient expediently in a location that is less disruptive.
- Experienced providers assess the needs of each patient, reducing unnecessary 911 responses, and speeding the decision to request one when needed.
- Providing helpful advice for most injuries, which don’t need follow-up, increases satisfaction and the likelihood that a participant will return.
The protocols a medical system works under must embrace this philosophy to empower providers to dispense this treatment, so all systems may not be able to adopt this operational philosophy.
