In November 2021, a music festival called Astroworld in Houston, Texas, claimed the lives of 10 individuals ranging in age from 9 to 27 years old, and injured hundreds.
The tragedy occurred in part because of poor execution of public health safety measures, leading to a $2 billion lawsuit against the performers and event planners.2 Such events prompt healthcare professionals to evaluate safety measures for mass gatherings, and to utilize technology, research, and interprofessional collaboration to limit morbidity and mortality related to mass gatherings.
Matt Friedman, MD, FACEP, serves as Associate Medical Director of Prehospital Care and Director of Event Medicine at Maimonides Medical Center and Medical Director of CrowdRx, which provides physician-led teams to staff medical services at mass gatherings. He is an expert in international mass gatherings. In this Q&A, Dr. Friedman shared his insights about event medicine and how residents and fellows can join this growing field.
What is event medicine and how did you get involved?
Event medicine is an emerging subspecialty that strives to improve the medical care offered at mass gatherings based on the understanding that such events generate a higher incidence of injury and illness than a similarly sized group of individuals, despite typically being a gathering of healthy individuals.
I became involved in event medicine after completing an EMS Fellowship at the Fire Department of New York (FDNY). There were two fatalities at the music festival Electric Zoo in New York in 2013, and I believe morbidity and mortality could be improved at these types of events if specialty-trained physicians are there to oversee them. I also noticed there were many young kids in their early 20s dying across the country and throughout the world, and I wanted people familiar with the pathophysiology to be able to treat them on-site.
What additional training can prepare EM physicians to be proactive and effective members of an MCI response team? Any fellowships you would recommend?
I believe that an EMS fellowship is essential training for the subspecialty of event medicine. EMS fellowship is generally an option for emergency medicine residents. I imagine that a resident completing any residency, with a strong interest in EMS, would be considered, although it would more likely be a challenging feat graduating from other specialties.
The skills and knowledge obtained during an EMS fellowship are instrumental to an MCI response team such as an Urban Search and Rescue team or a Disaster Medical Assistance Team. While there are fellowships that focus solely on disaster and not on the EMS aspect, and I may be biased, I think an EMS fellowship does a fabulous job of encapsulating the content of both in a one-year fellowship.
When preparing for mass gatherings, what safety measures are implemented to promote preparedness? Who are the key players in an efficient and effective MCI response?
There is a list of predictive variables that have been proven to determine the patient presentation rate (PPR), a statistic used to standardize the risk associated with all mass gatherings. The PPR for each event is calculated as the number of patient presentations per 10,000 patrons in attendance. The type of event is clearly important, for example, an electronic dance music concert versus a jazz fest. The ambient temperature, specifically the heat index, is an important variable contributing to the PPR. Whether the event is bounded like a music festival or unbounded like a marathon, and whether the patrons are seated or standing are all important predictive variables.
The key players are undoubtedly the producers of the event as they have to approve all decisions and all expenditures. However, producers must obtain permits from the hosting community to hold an event. Therefore, by granting permits to the producers, the local municipality has the power to get the promoters to do the right thing. The local municipality also typically involves their transit division to streamline the process of transporting tens of thousands of people to the event, as well as engaging local law enforcement and fire prevention services. Additionally, promoters hire a third-party security company to manage the crowd and ensure that critical access points and lanes are maintained for emergency vehicles.
What are some common medical emergencies related to mass gatherings?
This depends on the type of event. At EDM festivals, we commonly see MDMA-induced hyperthermia causing critical end-organ dysfunction and life-threatening arrhythmias. At outdoor participant events like triathlons and extreme obstacle courses, we see more orthopedic injuries, such as joint sprains and fractures. At heavy metal rock concerts, we tend to see blunt trauma from the mosh pits that inevitably arise. But common things being common, we see a ton of asthma and abdominal pain at mass gatherings. The difficult part is distinguishing between abdominal pain that is gastroenteritis or pancreatitis without laboratory diagnostic capabilities or imaging on-site.
How does the relationship between EM physicians and EMS play a role in an efficient response to an MCI?
It is so important for the EM or EMS physician on-site to understand the capabilities of the EMS providers on-site. In an MCI, EMS providers are empowered to quickly triage patients and act on those triage decisions. Therefore, the on-site physicians need to know if the EMS providers are competent at triaging. We should not spend 10 minutes on-site treating a black-tag patient when those interventions are unfortunately medically futile. We need to devote all of our resources to rapidly stabilizing and transporting the red-tag patients. It is key during an MCI for physicians to be able to instruct paramedics to intubate and transport a patient. If a physician is unsure of the EMS providers' capabilities, it will lead to confusion and wasted time rechecking EMS's actions.
What is your perspective on the recent Astroworld fatalities and what challenges do you believe the EMS and MCI response teams faced?
Unfortunately, the disaster at Astroworld was quite predictable. Stampedes have killed hundreds if not thousands of people at mass gatherings over the past 20 years, most notably at the Hajj, an incredibly large religious gathering in Saudi Arabia where the stampede risk factor is a concerning risk. Crowd control is a factor that many patrons are largely absent-minded about, but there is a reason why egress points are twice as large as ingress points and considerations like total attendance and forward flow are closely monitored. The particular problem with Astroworld was that 50,000 people were watching a single stage, which generally festival promoters try to avoid, instead of having multiple stages set up so there are fewer people per square foot. Additionally, this particular artist is known to incite mosh pits and reckless behavior by encouraging patrons to jump over barricades, push forward, and disrespect the presence of security.
What is fairly notable about Astroworld was that there were children as young as 10, 13, and 14 among the injured, so these were smaller people who were generally trampled and presumably asphyxiated. The decision not to stop the event immediately was probably the correct one because then there would be the potential for more stampedes among this crowd. What is still unknown is the precipitating factor for the stampede. Presumably, it was that people were just trying to get closer to the stage and not any sort of mass opioid overdose event that was initially reported. Also, some healthcare worker attendees at the festival later reported to the media that there were not enough trained medical personnel or equipment on-site to handle the casualties, though we cannot validate these claims. Having said that, it is fairly easy to get overwhelmed with more than two critically ill patients on-site. This is why critical access points and pedestrian-free lanes for first responders are vital during a mass gathering. It is incumbent upon security to ensure these lanes are maintained in order to quickly access critical patients.
What advice would you give to medical students and physicians attending large events who want to help as bystanders?
Some people carry an MCI trauma kit in their bag at these events. This kit might include a CPR pocket mask to act as a barrier during rescue breathing, non-latex gloves, gauze, a tourniquet, and perhaps a hemostatic dressing. CPR training is vital, however, if patients are in cardiac arrest during an MCI they are considered a black tag. It is better to move on to patients who can be saved by providing rescue breaths or hemorrhage control.
- Dillon N. Travis Scott, Drake, Apple, and Live Nation Facing New $2 Billion Astroworld Lawsuit. Rolling Stone. November 18, 2021. Accessed November 21, 2021.