The recent controversy over room capacity at presidential candidate Donald Trump’s political rallies point out very real issues surrounding such high-profile events. From operational concerns to public relations nightmares, this level of scrutiny nevertheless provides lessons for EMS and fire service personnel.

Many of us have worked special events and mass gatherings in the past and can speak from first-hand experience how large crowds are not just simply inconvenient, but potentially life-threatening for victims whose accessibility by EMS personnel is severely hampered. Heat, noise and confined space make an accurate patient assessment difficult. Face-to-face and radio communications with crews and dispatch are challenging. Removing a patient via gurney or litter may be impossible.

Meanwhile, citizen journalists — event attendees with their smartphones — are able to broadcast every EMS action. The musician, celebrity or politician may even pause their performance as EMS responds to the emergency — drawing additional attention and scrutiny.

Building codes, including occupancy limits, designated emergency exits and emergency responder ingress routes, exist because of historical losses of life in nightclubs, restaurants, arenas and businesses. Regulators and code-enforcement officials are smart to ask 'what if' questions about potential risks, not only to determine how likely a loss of life is, but how catastrophic that loss might be.

No one anticipates worst-case scenarios like a wall or stage collapse, bleacher failure, explosion or deadly fire. Too often, it’s only after damages have occurred that we realize saying ‘what if’ is much better than saying ‘if only.’

This year's political rallies are marked with a great risk of violence. Departments must over prepare to manage mass gatherings at political events. Interagency cooperation is an absolute must and ground coordination is essential for success. These types of rallies pop up quickly, often in just a few days, and agencies must be agile in their response.

For field providers, scene safety concerns are continuous. Close working relationships with law enforcement and event security will help create safer working spaces, such as in cases where a victim must be extracted from a crowded area to a safer location.

Several fire marshals have been publicly taken to task over their code enforcement duties. These codes, written by experts and supported by evidence, are designed for the safety and protection of the people who are attending events in high-occupancy, public buildings. Fire marshals are simply required by law to enforce these life safety regulations.

Nevertheless, as the recent rhetoric has shown, politics have a way of complicating matters. Agencies should be prepared to respond to public scrutiny of policies and procedures, because long after this controversy blows over, the same agencies will continue to serve and protect the public’s safety.

By Rong-Gong Lin II and Matt Hamilton
Los Angeles Times

FONTANA, Calif. — Three people died after attending a rave this weekend in the Inland Empire, the latest in a series of deaths that have fueled debate about safety and the need for stricter regulations of such concerts.

The victims were stricken at the Hard Summer rave, which was moved from the Los Angeles County fairgrounds in Pomona last year after two college students died of drug overdoses. This year’s Hard Summer was held at the Auto Club Speedway near Fontana, and despite last year’s deaths saw record attendance. 

Drug overdoses have been a recurring problem at electronic dance music festivals, where Ecstasy and similar club drugs are often used for their stimulating and euphoric effects.

Before this weekend, there have been at least 24 confirmed drug-related deaths nationwide since 2006 among people who went to raves organized by Los Angeles-area companies. Twelve have died in Southern California — four in San Bernardino County and eight in L.A. County — and five in the Las Vegas area.

Officials emphasized that they were still trying to determine causes of death for the concertgoers who died this weekend. One was found unresponsive, another had a seizure and a third was believed to be experiencing chest pain, L.A. County sheriff’s spokeswoman Jodi Miller said.

They were identified as Derek Lee, 22, of San Francisco and San Diego State student Alyssa Dominguez, 21, of San Diego, both of whom died Sunday, and UC Riverside student Roxanne Ngo, 22, of Chino Hills, who was declared dead on Monday.

Angel Ghaemi, 22, of Palos Verdes Estates, said she had been waiting for hours to leave a traffic-choked parking lot after the concert when she encountered a woman — who she later realized was Dominguez — dying.

Ghaemi, who said she was sober and had not consumed drugs, looked to her left at about 1:15 a.m. Sunday and saw a police officer attempting to give a woman CPR on a patch of grass in the parking lot. 

Ghaemi ran over and said the woman’s pupils were completely dilated and she lacked a pulse.

“I tried to do CPR and nothing was working,” Ghaemi said. “We really needed a defibrillator and an ambulance,” but the congestion in the parking lot seemed to slow first-responders. “I was there for 15 minutes until the ambulance came, and there was nothing they could do.”

The woman’s friends were sobbing and appeared in shock, Ghaemi said.

Two of Ghaemi’s friends later found the woman’s photo on Instagram and learned her name.

“I can never forget,” Ghaemi said. “She looked beautiful, that’s all I could think. It was the most surreal, life-changing moment of my life.”

On social media, family and friends of Dominguez remembered her as sweet and kind. A Twitter account appearing to be Dominguez’s showcased tweets of a summer of fun — hunting for Pokemon for a mobile phone game, hoping to win a stuffed animal at the fair, and gossip about her job waiting tables. 

Her last tweet was an image with a Hard Summer logo on it, warning of temperatures in the 90s, and telling attendees to dress lightly, stay hydrated and ask for help at any sign of illness. 

“21 is too young to die,” tweeted someone who said she was Dominguez’s older sister. “We can’t even see her because she’s gonna have an autopsy. Just a picture to identify her.” 

“I feel sick. I miss her so much,” she continued. “She really made me laugh.”

On a website that appeared to be written by Ngo, the UC Riverside student who died, the author said she was the youngest daughter of her Vietnamese immigrant parents. She was born in San Gabriel, grew up in West Covina and Chino Hills  and was working on a college degree in public policy “to pursue my goal in life to help those who are in need.”

“I have big plans for my future,” she wrote. 

While attending UC Riverside, Ngo also interned during the recent spring semester at the South Coast Air Quality Management District, according to an agency spokesman. She was credited with helping complete this year’s air quality management plan.

Tony Campisi, a coroner’s official, said autopsies have been ordered for all three young people, as well as toxicology tests to determine if drugs played a factor in their deaths. It could be several months before final causes death are determined. 

The three were among nine people transported to hospitals from the venue, Miller said. The two-day Hard Summer event brought nearly 147,000 people to the Auto Club Speedway, she said. This year’s edition of Hard Summer was billed as its biggest incarnation yet. 

There were 370 sheriff’s deputies working the event, Miller said, and 240 other security personnel. There were 325 arrests.

The speedway is owned by the International Speedway Corp., based in Daytona Beach, Fla., a publicly traded company that obtains 90% of its revenues from NASCAR-sanctioned racing events. Speedway officials did not return calls for comment. 

Temperatures near the venue site reached 92 degrees on Saturday and Sunday, according to the National Weather Service. 

In a statement released on behalf of the Hard Summer event promoter, Beverly Hills-based Live Nation Entertainment, one of the world’s largest concert and ticketing conglomerates, organizers expressed sadness over the three deaths. 

“We were deeply saddened to learn about the deaths of three people who attended the festival this weekend,” Alexandra Greenberg, a Hard Summer spokeswoman, said in a statement. “While the causes of the deaths have not yet been determined, we ask everyone to keep them in their prayers.  Our sincerest thoughts and condolences are with their family and friends.”

Hard Summer started as a much smaller event, held near Chinatown, and has grown into one of nation’s premier raves after it was acquired by Live Nation in 2012.

Rave promoters have defended their concerts, saying they’ve beefed up law enforcement and cracked down on drug use by attendees.

Hard Summer was moved this year to the Auto Club Speedway,  in an unincorporated area of San Bernardino County near Fontana, following debate by Los Angeles County supervisors over whether the fairgrounds should continue to hold raves after the two overdose deaths last summer. The board considered a moratorium on raves, but instead said it would increase regulation of gatherings of more than 10,000 people on county-owned land. 

Cal State Channel Islands student Katie Dix, 19, died of multiple-drug intoxication after ingesting a drug she thought to be the illegal drug Ecstasy at last summer’s Hard Summer event at the L.A. County fairgrounds,  according to the coroner and court records. Dix’s parents are suing Live Nation, the Fairplex, the county of Los Angeles and the city of Pomona, alleging negligence and accusing the entities of having “breached their duties to protect” rave attendees from people distributing or consuming illegal drugs.

The other woman, 18-year-old UCLA student Tracy Nguyen of West Covina, died of an Ecstasy overdose.

The deaths prompted several emergency room physicians in Los Angeles County to call for an end to large raves. 

Some venues — such as the  Cow Palace is San Francisco and the Los Angeles Memorial Coliseum — have stopped hosting raves because of drug problems.

But they have continued elsewhere, often farther away from city centers, such as at the San Manuel Amphitheater in Devore, which is owned by San Bernardino County and managed by Live Nation. 

“We've seen this all around the nation ... in L.A., it popped up in Chicago, in San Francisco, in New York,” Dr. Marc Futernick, emergency services medical director at Dignity Health California Hospital Medical Center in downtown Los Angeles, said last year. “There's something about these events that leads to this rampant drug abuse ... and young adults are really getting hurt and paying the price.”

Emergency room doctors have identified a couple of reasons why Ecstasy use at large raves can lead to severe illness, coma and death. One big problem is that Ecstasy can cause body temperatures to shoot up as high as 109 degrees, causing organ failure.

Dehydration can pose a problem, but so can drinking too much water, causing sodium levels to crash and triggering seizures that block oxygen to the brain.

Copyright 2016 the Los Angeles Times

By Frank R. Myers

If you work for a department in a major municipality or one that has any type of concert and sports venue or annual festivals, then you probably will need specialty scooters. With large crowds, tight areas and long walking distances to an exit, they are a good choice.

Here in Miami we have all these types of structures and events. Our scooters go back to the early 1960s and have evolved in design and types of fuel.

Our earlier scooters were bought with the now-demolished Orange Bowl Stadium in mind. They had three wheels, handlebars and an open cab; making tight-radius turns was not an issue.

Our newer four-wheel scooters did not have the same tight turning radius. Before the Orange Bowl was demolished, we did a test run with the newer scooters.

Although we were able to navigate them through the ramps at the Orange Bowl, it required practice. A different line and approach was needed to turn at the end of the ramps when the direction changed. As a result, we trained any personnel who would work there during events so they could maneuver and navigate those areas.

When Marlins Stadium was built we had a walkthrough to become familiar with the layout, travel paths, exits, etc. We ran the scooters through the structure to assure that we were able to maneuver without any complications.

Practice often
It is important to practice driving through any new structure where the scooters will be used. It accomplishes two tasks.

One, it improves responder ability to get to a patient quickly. Two, being familiar with the structure assures they know the most expedient way to move the patient outside to meet the transport unit.

A neighboring fire department, Miami-Dade County, uses two motorcycles staffed with paramedics. Once again, this provides easy navigation to reach and remove patients through dense crowds at large events.

One good way to work out all the bugs is to plan a drill such as a mass casualty incident or a structural collapse drill. These drills help address issues before problems occur in real-life situations.

A post-event critique can help relay and communicate any snags to the right personnel. These valuable lessons may impact current operating procedures.

Speccing it out
When specifying or fabricating EMS scooters, it is important to figure out how all of the medical kits, boxes, splints, defibrillators, patient stretcher, etc., are going to fit. Height is also important so the patient stretcher can be loaded and unloaded easily — you may need air shocks to raise and lower the rear of the scooter.

Try placing all items in the compartments to figure out what configuration works best and provides easy access. Consider what is essentials; a scooter cannot carry everything that would be on a full-size ALS transport apparatus.

Fuel type is another important consideration. If you work in an enclosed environment, propane or LP gas is the preferred choice for its reduced exhaust emissions.

Electric also may be feasible. Remember, it will have to haul a crew of two or three personnel plus a patient and equipment — so make sure the unit has enough power and endurance to handle ramps and other inclines.

At times, very large or multiple overlapping events may lead to a scooter shortage. The solution may be asking neighboring departments for their scooters, which may have different designs, handling capabilities and compartment configurations. Make sure to receive instruction on their operation from those respective departments.

Special use
Another area meriting special attention is operating these vehicles on public streets. Handling characteristics, visibility from the scooter, other vehicles and their ability to see you are different than your average fire department or civilian vehicle. It is especially important to have side mirrors and be accustomed to using them while driving.

Miami has a tunnel that serviced the Port of Miami. Our department purchased two ATVs for use in tunnel responses — one for the hazardous materials team and one for our technical rescue team.

These vehicles carried four crew members along with an attached trailer for tools, rope and extrication and firefighting equipment to address the type of incident. The trailer also doubled as a patient litter.

This required more training. A pick-up truck equipped with emergency-response lights, sirens and radio would tow the ATV on a trailer to the tunnel. Therefore, we had to train firefighters assigned to those stations who were unfamiliar about how to drive a vehicle towing a trailer.

Remember, we are talking about left turns, right turns, backing in a straight line, pulling up in front of the station and then backing into the apparatus bay, etc. It required practice, a certain skill set and knowing how to use the mirrors.

Who can handle it?
We required they pass a written test that covered things like safe operating procedures, load limits and terminology used in trailering vehicles. Not everyone has the skills to drive a vehicle with a trailer.

Those who could not pass the practical driving portion of the exam were not qualified to drive the pick-up truck and trailer.

Once a crew arrived on scene, the ATV would be off-loaded from the trailer. The trailer would then be unhitched from the pick-up truck and hitched onto the ATV.

Further training was needed for handling the ATV with a trailer; it is not as easy as you may think. Like with the pickup, the driver must be able to back up with trailer attached.

Some of you may already know it is easier to maneuver a tandem-axle trailer than a single-axle trailer. You soon learn that not everyone can accomplish this task and cannot be qualified to drive the ATVs with the trailer attached.

Be aware that these smaller vehicles are not necessarily easier to drive than the vehicles the department operates day to day.

Although they are fun, we need to remain safe and know our limitations since they do have different handling characteristics, especially at higher speeds when driving with street traffic.

They also have a higher tendency for rollover. Driving these vehicles on a regular basis keeps everyone in-tune to remain safe.

About the author

Frank R. Myers is a retired lieutenant with Miami Fire Rescue, where he served for 32 years. Before his retirement, he served at the training center for six years as the driver engineer instructor. He works as a consultant for PSTrax.com, a technology service that helps fire departments across the country automate their apparatus, equipment and inventory checks.

The recreational use of 3,4-methylenedioxymethamphetamine, better known as MDMA or Ecstasy, has been associated with large scale dancing events known as raves since at the least the mid-1980s. With the evolution of the electronic dance music and social acceptance of these once-underground events, raves have become nearly mainstream, drawing tens of thousands of participants to confined spaces to party.

The death of three participants at a well-known California rave again highlights the dangers of MDMA use under adverse environmental conditions and the need for EMS providers to be ready to rapidly access and manage patients who are in real danger of death.

MDMA is an amphetamine derivative, similar to methamphetamine. It stimulates receptors in the brain to release large amounts of neurotransmitters that in turn stimulate the sympathetic symptom.

In addition to well-known adverse effects associated with the cardiac system, another condition known as serotonin syndrome can be triggered by MDMA use. Hyperthermia is an outcome associated with this effect. Combine with long hours of significant physical activity in very warm, very humid environmental conditions, and that's a recipe for dehydration, hyponatremia and heat stroke. Even patients who are young and in good health are challenged to remain healthy under those metabolic and environmental conditions.

EMS providers have to be prepared to rapidly cool and hydrate patients who have collapsed during these events. Benzodiazepine administration is recommended to stop any seizure activity, which worsens the hyperthermia. Airway management is a must as most of the patients will be unresponsive and unable to protect their own airways.

Due to the illegal nature of the drugs involved, it's not easy to determine who is critically ill at any time — victims can be moved or hidden by friends in order to avoid detection and possible prosecution for drug crimes. Since it seems impossible to screen participants who may be carrying MDMA or synthetic marijuana into a concert venue, public safety needs to adopt a harm reduction model, where it's made explicit that a participant who is suffering from an overdose is considered a patient, not a detainee. The same goes for anyone who renders aid or reports the incident quickly.

Cooling stations, easy and obvious access to medical aid, and rapid egress paths to emergency departments are on-the-ground options that might reduce the potential for harm to party goers. Appropriate training to all safety personnel to manage large numbers of affected individuals can help reduce the stress associated with mass gathering events.

Finally, it's critical that we are at our best when covering and responding to high-profile events. With that many people watching and recording, what we do not only goes a long way to support the patient, but also to promote the industry and profession as well.

By Todd Richmond
Associated Press

MILWAUKEE — Police said one person was shot at a Milwaukee protest on Sunday and officers used an armored vehicle to retrieve the injured victim and rush the person to a hospital, as tense skirmishes erupted for a second night following the police shooting of a black man.

Some two dozen officers in riot gear confronted about 150 people who blocked an intersection near where the black man was fatally shot Saturday afternoon, and more arrived. Police moved in to try to disperse the crowd and warned of arrests after protesters threw bottles and rocks at police.

Local television showed a small group of protesters running through the streets, picking up orange construction barriers and hurling them out of the way. Police tweeted three locations where they said shots were fired. There were no other reports of injuries at Sunday's protests and no widespread destruction of property.

Earlier in the day, police Chief Edward Flynn said the man whose death touched off Saturday night's rioting was shot after he turned toward an officer with a gun in his hand.

Flynn cautioned that the shooting was still under investigation and authorities were awaiting autopsy results, but that based on the silent video from the unidentified officer's body camera, he "certainly appeared to be within lawful bounds."

At the same news conference, Mayor Tom Barrett said a still image pulled from the footage clearly showed a gun in 23-year-old Sylville K. Smith's hand as he fled a traffic stop Saturday.

"I want our community to know that," Barrett said. But he also called for understanding for Smith's family.

"A young man lost his life yesterday afternoon," the mayor said. "And no matter what the circumstances are, his family has to be hurting."

Flynn declined to identify the officer who shot Smith but said he is black. The police chief said he wasn't sure what prompted the stop but described Smith's car as "behaving suspiciously." The officer involved was 24 years old and has been on the force for three years, according to the department.

After watching the officer's body camera footage, Flynn said the entire episode took about 25 seconds, from the start of the traffic stop until shots were fired. He said Smith ran "a few dozen feet" and turned toward the officer while holding a gun.

"It was in his hand. He was raising up with it," the chief said. He said the officer had told Smith to drop the gun and he did not do so. It was unclear how many rounds the officer fired. Smith was hit in the chest and arm, Flynn said.

Wisconsin Gov. Scott Walker put Wisconsin's National Guard on standby, and 125 Guard members reported to local armories to prepare for further instructions. Milwaukee police tweeted late Sunday that the National Guard had not been deployed.

Six businesses were burned in the unrest earlier in the weekend and 17 people people were arrested, Flynn said. Four officers were hurt from flying concrete and glass, although all of them had been released from hospital.

Milwaukee Alderman Khalif Rainey, who represents the neighborhood that erupted, said the city's black residents are "tired of living under this oppression."

"Now this is a warning cry. Where do we go from here? Where do we go as a community from here?" he asked.

Milwaukee County Sheriff David Clarke said Smith had been arrested 13 times. Online court records showed a range of charges against Smith, many of them misdemeanors.

The Milwaukee Journal Sentinel reported that Smith was also charged in a shooting and was later charged with pressuring the victim to withdraw testimony that identified Smith as the gunman. The charges were dropped because the victim recanted the identification and failed to appear in court, Chief Deputy District Attorney Kent Lovern told the newspaper.

Smith's sister told The Associated Press that the family wants prosecutors to charge the officer who shot him.

Kimberly Neal, 24, spoke as supporters surrounded her at the vigil as she held a bouquet of blue balloons.

She asked people for donations for his burial.

Asked about the violence, Neal said: "People stuck together and they are trying to stand up," for their rights.

The anger at Milwaukee police is not new and comes as tension between black communities and law enforcement has ramped up across the nation, resulting in protests and the recent ambush killings of eight officers in Baton Rouge, Louisiana, and Dallas.

Nearly 40 percent of Milwaukee's 600,000 residents are black, and they are heavily concentrated on the north side.

Milwaukee was beset by protests and calls for police reform after an officer shot and killed Dontre Hamilton, a mentally ill black man, in 2014.

In December, the U.S. Justice Department announced it would work with Milwaukee police on changes.

Critics said the police department should have been subjected to a full Justice Department investigation like the one done in Ferguson, Missouri, after the killing of black 18-year-old Michael Brown in 2014 touched off violence there.

By Etta Lucas

Anything can happen when there are thousands of spectators attending a large event.  With over 150,000 spectators expected to attend the 2016 MCAS Cherry Point Air Show, planning and preparations began months prior to the event.  In preparation for the Air Show, numerous exercises were conducted.   Air Show staff were guided through several table top exercises, communications exercises and a full scale mass casualty exercise.

After the initial viewing of the webcast, Mr. James Riemer, Director of Operations, MCAS Cherry Point, and Air Show Director, recommended the webcast be shown for the entire Air Show staff and highly recommended that staff join the association in order to participate in future webcasts.  That being said, I joined the IPSA as a Member in order to be part of an organization that unites all public safety groups.

Mass casualty training and exercising are important when planning mass gatherings because emergencies can happen at any time.  In an effort to understand how others have dealt with Air Crash mass casualty events and through the assistance of Ms. Heather Cotter, Executive Director, International Public Safety Association (IPSA), the MCAS Cherry Point Operations staff was able to review the Reno Air Races: Responding to "A Plane in the Stands" webcast. 

Many webcasts have since been viewed; however the Reno Race webinar provided our staff the opportunity to see how other agencies operate and it reinforced how important it is to collaborate with outside agencies.  Our participants saw further evidence that pre-planning for events of this magnitude is important in order to define roles and responsibilities, identify and properly deploy resources, and to discuss contingency plans with our partnering agencies.

Although we have our Pre-Air Show Mishap Plans and an All Hazards Plan that includes Mass Casualty Incidents; the Reno Air Race webcast provided our staff valuable information regarding Emergency Evacuation on a large scale.  Prior to viewing the webcast, Ms. Cotter provided contact information and introduced our staff to Mr. Kevin Romero, Director, Regional Emergency Medical Services Authority and the Reno Race guest presenter.  Mr. Romero was very helpful in providing additional information and planning tools and flow charts.

After reviewing the webcast and discussing the Reno Race Mass Evacuation Plan, our staff met with local police and the North Carolina State Highway Patrol to discuss our Emergency Mass Evacuation Plan.   Our Evacuation Plan was reviewed and roles and responsibilities defined.  We discussed egress routes for emergency and non-emergency traffic, the importance of which was clearly stated during the Reno Race webcast.

Fortunately, we were untested by a major mishap during our Air Show.  However, an unanticipated record number of visitors to the Air Show on the second day of the event created a 10-mile gridlock on eastbound Hwy US 70, the only major traffic corridor through the local area.  This resulted in the potential for significant problems in the event of a major mishap. 

In retrospect, we realized that we had not sufficiently discussed mass gathering ingress during our planning meetings.  We are now re-writing our plans to include ingress and egress, as MCAS Cherry Point relies on one of eastern North Carolina’s major east-west highways (US 70).  With our closest Trauma Center located approximately 112 miles to the west, and our closest hospitals 20 miles in either direction (east and west) on US 70, the main artery to and from our base is a four-lane highway that we cannot afford to have closed in either direction.  We believe lessons learned from the Reno Air Race seminar will continue to help us mitigate future traffic challenges for emergencies … or for perfect Air Show days.

Reprinted with permission of IPSA.

About the author
Etta Lucas served as the Installation Emergency Manager, Mission Assurance at the Marine Corps Air Station, Cherry Point.

Whether you are at a high school football game, a music festival or a major league sports event, EMTs providing event medical services need to be able to respond quickly to any call for help. Responding quickly is half of the equation to success. Having the right tools to render the appropriate care is the other half.

The majority of responses or patient contacts often don’t require a visit to the onsite medical office, much less transportation to an emergency room. Improving a guest’s condition so they can enjoy the rest of their time in the venue is the primary goal of every event medical service provider.

Standard Items
In order to meet expectations of the organizer and their guests, event medical service providers need to have the tools on hand to be prepared to face a variety of possible issues. Knowing the organizer's expectations for event medical services, as well as the capacity of on-location medical services and the availability of a dedicated transport unit is important to fine-tuning the supply list.

Here is a list of typical supplies for quick response by an event medical service provider on a posting:

Circulation: Bleeding control supplies

• Adhesive bandages 1x3” (20)
• 4x4 gauze (10)
• 5x9 gauze (5)
• 10x30 trauma dressing (1)
• 1-inch medical tape (1)
• 2-inch medical tape (1)
• Triangular bandages (4)
• Burn sheet (1)
• 1-inch roller gauze (3)
• 2-inch roller gauze (3)
• 250 mL sterile saline (1)
• Trauma tourniquets (2)
• Trauma shears (1)

Airway: BLS management

• Oropharyngeal airways (OPA) sizes 0-5 (1)
• Portable handheld suction unit (1)

Breathing: Ventilation and oxygenation

• D-size oxygen cylinder with oxygen regulator (1)
• Adult BVM w/ 2 masks (1)
• Pediatric BVM w/ 3 masks (1)
• Adult non-rebreather mask (2)
• Adult nasal cannula tubing (1)
• Pediatric non-rebreather mask (2)
• Pediatric nasal cannula tubing (1);

Additional items for assessment and care

• Adult blood pressure cuff (1)
• Pediatric blood pressure cuff (1)
• Adult stethoscope (1)
• Pediatric stethoscope (1)
• Chemical ice packs (4)
• Small splint (1)
• Small red infectious waste disposal bag (2)
• Notepad for documenting patient information (1)
• Black ink pen (1)
• Penlight (1)
• Flashlight (1)
• Personal protective equipment kit including gloves, gown, goggles, and respirator (1)

The following should be carried if allowed by local protocols:

• Nebulizer and albuterol sulfate doses (1)
• Nasopharyngeal airways airways sizes 16F-34F (1)
• Adult epinephrine auto-injector (.3 mg) (1)
• Pediatric epinephrine auto-injector (.15 mg) (1)
• Blood glucometer (1)
• Pulse oximeter (1)

An AED with each medical provider is ideal but not a necessity. The venue may have public access AEDs readily available to use. For venues without AEDs, overlap concentric circles of coverage with 50 percent of your postings equipped with AEDs.

Increasing Options Through Supply
While traditional emergency medical services often stock to regulatory minimums with just enough to get the patient to the hospital for definitive care, event medical services workers often add additional items so that guests who have received treatment can stay and keep enjoying the event. While remaining in the venue is not always possible due to the guest’s condition, transporting every patient that comes to a first aid station is simply unnecessary.

Part of the reason for this philosophical difference is reimbursement models. While the emergency medical service is reimbursed on a transportation fee-for-service model, the vast majority of event medical service providers are reimbursed on an hourly or per-event basis. By doing this, event medical services do not depend on patient transportation for financial solvency.

Some ambulance transport agencies may reduce their pricing for staffing an event under the assumption that there will be some number of patient transports resulting in reimbursement. Agencies should never count on patient transport reimbursement when bidding and budgeting for events. Doing so incentivizes the providers to the traditional emergency medical services philosophy to transport patients to a hospital, which is a disservice to the event organizers and their guests.

One way to be sure you can address the needs of the guest is to have the additional items on hand to care for them in the best manner.

Specific items for event coverage

• Knuckle articulated adhesive bandages 1½ x 3” (5)
• Fingertip adhesive bandages 1¾ x 2” (5)
• Adhesive bandage strips ½ x 4” (10)
• Triple antibiotic ointment .5g (10)
• Sterile saline irrigation solution 30 mL (5)

Over-the-counter medications
There is usually a debate surrounding over-the-counter medications and whether or not they can be furnished to guests. Some argue that providing these medications is drug administration, while others, me included, view the drugs as just being dispensed.

The four over the counter medications most commonly requested are acetaminophen, ibuprofen, diphenhydramine, and aspirin. One way to avoid any and all legal issues is to not offer any over-the-counter drugs.

Unfortunately, just as we wonder why the public can easily access naloxone for drug overdoes, the public you come into contact with will wonder why we can’t provide them a packet of aspirin for a headache. The worst part is that your level of service will appear sub-par to those guests when compared to the local 24-hour convenience store.

Some ways to resolve the arguments on this topic include providing only individual dose packages. Some services charge the requestor a fee for each packet while others roll the cost of over-the-counter drugs into their fee to the venue and dispense it gratis.

The provision of drugs may require standing orders from a medical director. In some extreme situations a complete patient assessment and a patient-signed refusal of medical aid are also required. Ultimately refer to your local protocols and your legal counsel when making the decision whether or not to include the over-the-counter medications.

Kit bag considerations
There are a number of factors to take into consideration when choosing the type of bag to hold your response kit. Providers posted without a patient transport device will likely request a hands-free, backpack-style bag.

Another kit consideration is organization of the bag. The majority of injuries and ailments that providers respond to are minor aches and wounds. For this reason a bag with easy to access outer pockets where the adhesive bandages, tape, triple anti-biotic ointment packets and chemical ice packs can be reached is a great choice.

When opening the bag you don’t want the contents spilled out all over the concourse, street or festival field where guests are walking or risk items falling behind seats. A bag with individual removable interior pouches, preferably color-coded for quick selection, is again ideal in this type of environment.

The material the bag is made of makes a difference, especially in stadium and open air settings. Precipitation often will cause a spike in call volume and you want to make sure that you protect your supplies against those elements. A non-porous, water-resistant material is the best choice to defend against bad weather and for the easy decontamination.

Regardless of bag type, do not overload the bag. Excessive contents lead to broken straps, blown-out stitching, holes and rips. Just as it matters in the traditional emergency medical services, appearance and perception to the public are important in the event medical services.

Cell phone video and livestreaming puts event medical providers under a microscope to the world. Make the best impression you can with your gear, your uniform, and most importantly, your attitude towards the guests.

The 15th anniversary of the Sept. 11 attacks is upon us. For many of us, that day was a transformative moment in time, when "terror attack" became a household phrase and billions of dollars were spent strengthening homeland security.

Over the years, ceremonies have been held, memorials built and museums created to record this date in American history. However, I suspect that most of us who were EMS providers on Sept. 11, 2001 will spend a part of the day in quiet reflection, thinking about what we were doing at the time and the rush of mixed emotions as hundreds of public safety providers and thousands of civilians lost their lives.

During the past 15 years, the lessons learned from a multitude of events are becoming clear. Here are my top four lessons to remember.

Lesson #1: Violent, large sale attacks will occur at any time and in any place.
Regardless of our efforts to prevent them no venue — schools, theaters, workplaces, public spaces, concerts or military installations — and no segment of the population is totally immune from a lone wolf or well-coordinated group.

Lesson #2: EMS must be prepared.
Because of lesson #1, EMS and other public safety agencies must be trained, equipped and prepared to respond to these incidents. "It will never happen here" should never be in a public safety provider’s vocabulary, nor can it be the mantra of a response agency.

Lesson #3: Preparation is easier said than done.
Even though a lot of money has been spent on homeland defense and security, the level of response to domestic attacks has been inconsistent. Government must continue to provide funding necessary to support agencies in their efforts to prevent and respond to major incidents. Agencies must ensure that plans, training and resources are appropriate and relevant. Providers must take the training seriously

Lesson #4: Planning and training must be multijurisdictional.
Current Department of Homeland Security guidelines recommend early entry of EMS providers into a warm zone to initiate basic trauma care, while being escorted and guarded by law enforcement officers. The rescue task force might seem like a crazy idea, but it becomes doable if there is enough training for EMS providers and law enforcement officers to be more comfortable and confident working together. Communications among agencies is critical to operational success, from radio systems to common language and protocol.

A final note: I know that many EMS1 readers were barely in grade school in 2001. For you, 9/11 is truly a piece of history, perhaps abstract and hard to grasp its significance to EMS in 2016. Sadly, there have been many incidents since then — Sandy Hook, Boston, San Bernardino, Aurora, Blacksburg and Orlando.

I hope that you understand how important you are to the safety fabric that wraps around your community. Most days, maybe all days, you’ll perform your duties without fanfare and without public recognition. However, when that horrible day comes, you will be asked to perform above and beyond the call of the every day. Your community depends upon that.

Medical coverage for high-profile mass gatherings, like a presidential candidate debate, is a critical, but often overlooked element of the complex and intense preparation activities of public safety personnel. 

Planning for the October 9 debate between Donald Trump and Hillary Clinton at Washington University in St. Louis began many months before the two candidates met on stage. This was the fifth debate held at the University since 1992.

Here are some of the important and shareable takeaways from my participation as the EMS medical director in planning, logistics and operations of this event.

Tight security logistics
A presidential debate is definitely a mass gathering event, but the added element of tight security posed a unique logistical challenge when planning ingress and egress routes for crews and apparatus. Because access to the debate hall itself was tightly controlled and restricted, medical coverage to immediately stabilize, treat, then transport any serious medical emergency was a high priority leading to the development of an on-site, pre-staged medical team.

Medical equipment for the on-site, pre-staged medical team also had to be brought in several days beforehand for screening and security clearance. So pre-planning for necessary medications, equipment and supplies was essential. 

Debate hall medical crew
The composition of the debate hall medical crew included an EMS physician and four paramedics. If needed, the team would initiate emergency treatment while simultaneously working with the Emergency Operations Center on campus to coordinate ambulance pickup.   

The debate stage ready for the candidates. (Photo courtesy Washington University in St. Louis Facebook page)

Multiple medical operation areas
Additionally, the debate hall was only one of several areas of operation that needed medical coverage. Large numbers of police, fire and EMS personnel were assembled in strategic areas to cover routine calls in and immediately surrounding the Washington University campus. Public safety personnel were also positioned to form a quick response contingency should civil unrest or other incidents unfold.

Journalists from around the world cover the Debate from the media work area. (Photo courtesy Washington University in St. Louis Flickr page)

Strategically placed resources helped reduce response times that were significantly degraded due to the extensive traffic re-routing patterns and road closures required for security purposes. 

Multi-day incident
Though the debate only lasted for 90 minutes on Sunday evening, many first responders started arriving and staging on Friday to provide medical services to the hundreds of personnel assembling for the event. Medical force protection assets were available in the various staging areas. A cadre of paramedics, along with one or two EMS physicians, formed the core element of these rapid response force protection medical assets.  

Hillary Clinton speaking at the Debate. (Photo courtesy Washington University in St. Louis Facebook page)

Anticipating traumatic injury
Scores of protestors arrived on campus making the trauma potential from thrown objects or even biological substances a major concern. Medical response teams were created to rapidly extract injured personnel and were equipped with rapid decontamination capabilities and blunt trauma kits. Mutual aid paramedics were brought in to staff these teams and were augmented by EMTs from the university's campus-based EMS system.

Public expression zone at the intramural fields located on the campus. (Photo courtesy Washington University in St. Louis Flickr page)

A heavy security presence to help protect law enforcement and medical teams seemed to be an effective deterrent during the weekend and throughout the debate itself. 

Less than 3 hours until #WashUdebate2016! Our officers are out in full force, standing alongside other area agencies, on & around campus. pic.twitter.com/BYbMIOM85O

— St. Louis, MO Police (@SLMPD) October 9, 2016

Value of NIMS and IAP
The value of using and adhering to principles of the National Incident Management System cannot be overstated. The entire Incident Action Plan was continually updated in an organized and step-wise manner.

In addition to ensuring medical response capability, the IAP also included scheduled clinic hours for the hundreds of personnel on campus who may have sustained a minor injury or illness during their operational period. An on-site clinic made it possible for essential workers to obtain an evaluation while optimizing their chances of performing and completing indispensable tasks. The clinics were staffed by EMS physicians and at least two paramedics with arrangements made with a local pharmacy to expedite delivery of medications. 

Communication to medical control
In ICS, the operational medical assets are under Operations section and force protection medical assets are under the Logistics section. Which means the medical component of such a large and complicated operation may span across an IAP making the importance of good communication and pre-planning even more crucial. Having access to direct medical control in the form of physicians experienced in the subtle complexities of field care can also be advantageous especially in the rapidly changing environment of a mass gathering event with high potential for prolonged operations and evolving hostilities. 

Mass gathering principles of EMS preparation and planning become more complicated when high profile and high-security elements are introduced. Frequent plan revisions are to be expected, but can be attenuated by a well-organized NIMS approach and reliance on trusted community partners to provide assistance.