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Michael J. Feldman, MD, PhD, Jane L. Lukins, MBBS, P. Richard Verbeek, MD, Robert J. Burgess, ACP, Brian Schwartz, MD Providing medical care at mass gatherings presents
Introduction. Paramedics provide a substantial proportion
unique challenges. Many patients do not require trans- of care at mass gatherings but do not typically release pa- port to community hospitals if appropriate manage- tients without physician assessment. Objective. To evaluate
ment and disposition are available at the event.1 A treat-and-release medical directives implemented at a large variety of strategies are used to limit the number of single-day summer rock concert. Methods. Medical directives
allowed paramedics to administer acetaminophen, dimenhy-
transports off site and reduce the impact on hospitals in drinate, diphenhydramine, or polymyxin B ointment for com- the community. These usually include the implementa- mon complaints without evidence of serious illness on history tion of field hospitals staffed by physicians and nurses, or examination. After treatment, patients were released or first-aid units staffed by a variety of personnel, and mo- transferred to a medical facility according to predefined cri- teria. Patient demographics, chief complaint, treatment, and Although paramedics provide a substantial propor- disposition were obtained from paramedic records. To de- tion of care at many mass gatherings,3,4 they do not termine whether any patients released by paramedic subse- typically possess the authority to release patients af- quently required ambulance transport, all ambulance records ter treatment. Given this limitation, one rationale for were searched for a period of eight hours before to 24 hours having on-site physicians at mass gatherings is to re- after the event. Results. More than 450,000 people attended
duce the need for off-site ambulance transports.1 Treat- the concert, with 1,870 presenting for medical attention. Fourhundred seven patients received medications under the di- and-release medical directives may be another means rectives. No disposition was recorded in 13 cases. Two hun- of limiting the need for physician assessment or off- dred ninety-nine patients were treated with acetaminophen, site transport, but the use of such directives at mass of whom 269 (90.0%) were released and 23 (7.7%) required ad- gatherings has not been previously described. Limited ditional care. Sixty-two patients received dimenhydrinate, 44 experience with such protocols had been accumulated (71%) were released, and 14 (23%) required transport. Thirty- at smaller mass gatherings in Toronto, but no system- six patients received diphenhydramine, and 34 (94%) were re- atic review with respect to their role or effectiveness leased. Ten patients received polymyxin B and were released.
No patient released by paramedics was found to have later re- During the “Toronto Rocks!” Rolling Stones 12-hour quired ambulance transport. Conclusions. Treat-and-release
outdoor concert held on July 30, 2003, with an ex- medical directives for paramedics at mass gatherings may pected attendance of 500,000 spectators, several mea- help divert patients from requiring care at a medical facility.
Future research is needed to determine the safety (morbid- sures were taken to provide as much on-site medical ity and mortality) of these directives. Key words: emergency
care as possible. These included implementation of a 76- medical services; paramedic; treat and release; mass gather- bed field hospital, a 48-bed medical rehydration unit, and five freestanding first-aid tents. The field hospital PREHOSPITAL EMERGENCY CARE 2005;9:213–217 and rehydration unit were staffed with physicians whowere responsible for patient discharge and disposition,while the first-aid tents were intended to be staffed byparamedics who could discharge selected patients us- Received April 2, 2004, from the Division of Prehospital Care, ing treat-and-release medical directives.
Sunnybrook and Women’s College Health Sciences Center (MJF, We describe and evaluate medical directives de- JLL, PRV, RJB, BS), Toronto, Ontario, Canada; the Department of signed to allow paramedics to treat and release patients Emergency Medicine, Kingston General Hospital (MJF), Kingston,Ontario, Canada; and the University of Toronto (JLL, PRV, RJB, with minor illnesses and injuries at a mass gathering.
BS), Toronto, Ontario, Canada. Revision received August 11, 2004;accepted for publication August 11, 2004.
Presented in preliminary form as a poster at the National Association of EMS Physicians annual meeting, Tucson, Arizona, January 2004.
Toronto Emergency Medical Services (EMS) is the Address correspondence and reprint requests to: Brian Schwartz,MD, Sunnybrook and Women’s College Health Sciences Center, Di- sole EMS provider for the city of Toronto. Medical vision of Prehospital Care, 10 Carlson Court, Suite 640, Toronto, ON, oversight is provided by EMS physicians working M9W 7K6, Canada. e-mail: <>.
with the Base Hospital Program of the Sunnybrook and Women’s College Health Sciences Center. Current paramedic protocols in Toronto do not typically per- starting eight hours before the concert and ending 24 mit a paramedic to treat and release patients, although hours after the concert. A hand search of these records patients requesting not to be transported can sign a re- was conducted to determine whether there were any lease form if they have the capacity to consent to or instances in which patients required transport after re- lease by paramedics within 24 hours.
In order to limit the need for physician assessments The study was approved by the Sunnybrook and at the concert, a series of special-events medical direc- Women’s College Health Sciences Center Research tives were designed to allow paramedics to administer four medications that were not within their usual scopeof practice. These included acetaminophen 650 mg per os (po) for headache or mild musculoskeletal pain, di-menhydrinate 25 to 50 mg po for nausea and/or vom- More than 450,000 people attended the concert, with iting, diphenhydramine 50 mg po for allergic rhinitis 1,870 (42 per 10,000 attendees) presenting for med- or isolated urticaria, and polymyxin B ointment for ical attention. A substantial proportion of patients small wounds not requiring sutures or d´ebridement.
were simply requesting water, sunscreen, or bandages.
The medical directives are shown in the Appendix.
Records were not taken of these encounters. Records On the day of the concert, paramedics attended a were obtained for 1,205 patients, of whom 703 were one-hour briefing in a nearby staging area. The brief- treated at the first-aid tents. Of these 703 patients, 407 ing consisted of an overview of the site, access routes, (58%) received medications under the treat-and-release site communications, and instruction in the use of the special-events medical directives. Paramedics were in- Table 1 summarizes the number and disposition of structed to assess vital signs, allergies, contraindica- patients treated under the special-events medical di- tions to treatment, and signs or symptoms of serious rectives. The average patient age for those who were underlying illness. All directives included predefined treated with medications under the special-events med- criteria for transfer to a site medical facility. Patients ical directives was 28 years (range 12 to 61), and 66% who were candidates for release were advised of the were female. Overall, 357 (88%) patients out of 407 availability of medical facilities at the concert and that treated under these directives were released.
they should seek additional care at their own discretion Disposition was not recorded in 13 (3%) cases, but if their symptoms persisted or worsened.
the search of all 758 ACRs in the city of Toronto from After treatment, a paramedic could release the pa- eight hours before the concert until 24 hours after the tient or transfer him or her for physician assessment.
concert showed that none of the patients treated under Those deemed suitable for release could be released by these protocols required subsequent ambulance trans- paramedics without direct physician–patient contact fer from the concert to community hospitals. In addi- and without contacting online medical control. Lack tion, no patient who was treated under the special- of a satisfactory response to treatment usually indi- events medical directives and subsequently released cated the need for transfer to the on-site medical fa- by paramedics later required Toronto EMS transport cility or to hospitals in the community. Online medical within 24 hours after the end of the concert.
control physicians were consulted to determine dispo-sition only for those patients identified by paramedics DISCUSSION
All off-site ambulance transports to a community Mass gatherings represent a significant medical and hospital required use of the standard ambulance call re- logistic undertaking for a community. Various strate- port (ACR) used in the Province of Ontario. For all other gies are employed to mitigate the effect of the event patient encounters requiring treatment, a pocket-sized on EMS resources and community hospitals. Although notebook filled with patient contact reports (PCRs) wasissued to each paramedic. The PCRs were an abridgedversion of the ACR developed to facilitate record keep- TABLE 1. Number and Disposition of Patients Treated under the Special-Events Medical Directives at the Concert∗ ing for brief patient encounters during the concert. AllACRs and PCRs were collected immediately after the concert. Data abstracted included patient demograph- ics, chief complaint, time of incident, initial vital signs, Although there was no formal follow-up conducted to determine whether patients released by paramedics subsequently presented to their physicians or to hos- pital emergency departments on their own, all ACRs ∗Totals may not add up to 100% due to incomplete recording of patient for Toronto EMS were collected for a 48-hour period TREAT-AND-RELEASE MEDICAL DIRECTIVES AT MASS GATHERINGS the composition of site medical teams usually includes who wish to refuse treatment and transport must be volunteer first aiders, paramedics, registered nurses, assessed for mental capacity to determine their abil- and physicians, a substantial proportion of prehospi- ity to make an informed decision and they must be tal care in these settings is rendered by paramedics.
advised of the risks of refusing treatment and trans- One prospective study of patients presenting at mo- port. The treat-and-release directives used at the con- torized vehicle races showed that direct physician care cert were implemented for a single, daylong event and or physician oversight was needed to provide care to were limited to patients with apparent mild complaints nearly half of the patients.1 The authors speculated that and no evidence on history or physical examination protocols could have been implemented at the mass of serious underlying disease. Our target population gathering that would allow paramedics to treat and re- included a large proportion of younger and presum- lease patients who met predefined criteria.
ably healthy adults attending a large rock concert. More Release of patients by paramedics without physi- than one-third of patients presenting for medical aid cian assessment is an area of controversy in prehospital at the concert were treated using these directives, and care. One report found that 2% of patients who initially 88% were released without physician assessment. The refused transport called 9-1-1 again within 48 hours patients treated in first-aid tents under the treat-and- with a chief complaint related to their original prob- release medical directives were nearly as numerous as lem. These patients tended to be older (over 65 years) the 465 patients treated in the field hospital and would and all were transported on the second call. More than likely have represented a substantial challenge to the half required hospital admission and one died en route field hospital had all been transferred there for physi- to the hospital.6 Another study in rural New York cian assessment. Of the 39 patients treated under the di- State showed that 48% of patients who initially refused rectives but subsequently transferred to the rehydration transport later sought medical care, with one-fourth unit or field hospital, all were eventually discharged requiring admission, and with one death in hospital.7 home or back to the concert, suggesting that paramedics Paramedic-initiated refusals are also problematic, with were capable of safely selecting patients with mild, un- 18% reporting dissatisfaction with the paramedics’ as- sessment and care and 22% later requiring hospitaladmission.8 A more recent attempt to use a formal pro- LIMITATIONS AND FUTURE STUDY
tocol to have paramedics identify patients who maynot require ambulance transport did not achieve sat- This prospective observational study had inherent de- isfactory results. Among 47 patients for whom hos- sign limitations. There was no comparison group to pital follow-up was available, eight were admitted determine whether released patients fared differently to hospital, with three requiring monitored beds.9 from those receiving traditional physician evaluation.
Finally, patient refusals pose significant medicolegal No follow-up was arranged, nor was there any mea- concerns, with nontransport occasionally resulting in sure of patient outcomes, response to treatment, or re- lapse requiring additional medical care. Although the There are few published studies on paramedic treat- review of all ambulance transports and cancelled calls and-release medical directives, with the majority eval- for the 24 hours after the concert found no instance of a uating protocols for diabetic patients with hypo- patient released under our protocols who required an- glycemia. In one small series, patients could be released other ambulance, patients presenting on their own to if their blood sugar, mental status, and vital signs had physicians or hospitals, or deaths to which there was no normalized, if they were not vomiting, and if they were ambulance response would have been missed. Future not taking oral hypoglycemic agents. One patient out of implementation of these directives for mass gatherings the 38 enrolled developed hypoglycemic encephalopa- should have formal follow-up arranged, as a large data thy after release and required admission to a long-term set that can support or refute the safety of treat-and- care facility.11 A study in Helsinki showed that 32.5% release directives would be an important contribution of hypoglycemic patients released after administration of intravenous or oral glucose required an ambulance The treat-and-release directives described herein and 95% sought care from their physician during a were not developed for the general population of pa- three-month follow-up period.12 No data on adverse tients who call 9-1-1, nor would they necessarily be outcomes were reported. Other studies showing rates applicable to different demographic groups, weather of recurrent hypoglycemia of between 2% and 9% and conditions, or other types of mass gatherings. Patients hospital admission rates of between 2% and 3% point to attending the concert tended to be relatively young, and the relative safety of not transporting these patients.13,14 many of the patient presentations were due to heat and However, both of these studies were limited by small environmental exposure rather than underlying medi- cal conditions. During the concert, crowd conditions at In our current system, we do not normally use treat- times severely restricted the movement of ambulances and-release medical directives for 9-1-1 callers. Patients between the first-aid tents and the rehydration unit or field hospital. This problem was addressed by sending 3. Wetterhall SF, Coulombier DM, Herndon JM, Zaza S, Cantwell physicians to the first-aid tents to help with patient JD. Medical care delivery at the 1996 Olympic Games. JAMA.
management and disposition for those not meeting the 4. Grange JT, Baumann GW. The California 500: medical care at a directives. It is possible that there were instances of un- NASCAR Winston Cup Race. Prehosp Emerg Care. 2002;6:315–8.
documented physician input to paramedics using the 5. Basic Life Support Patient Care Standards, Version 1.1. Toronto: treat-and-release directives to manage patients in first- Ontario Ministry of Health and Long Term Care, 1999, p 20.
6. Moss ST, Chan TC, Buchanan J, Dunford JV, Vilke GM. Outcome study of prehospital patients signed out against medical adviceby field paramedics. Ann Emerg Med. 1998;31:247–50.
7. Burstein JL, Henry MC, Alicandro J, Gentile D, Thode HC Jr, Hollander JE. Outcome of patients who refused out-of-hospital Treat-and-release medical directives for paramedics medical assistance. Am J Emerg Med. 1996;14:23–6.
providing care at mass gatherings allows the release 8. Zacharia BS, Bryan D, Pepe PE, Griffin M. Follow-up and outcome of selected patients and may divert patients from re- of patients who decline or are denied transport by EMS. PrehospDisaster Med. 1992;7:359–64.
quiring care at an on-site medical facility, or from being 9. Schmidt TA, Atcheson R, Federiuk C, et al. Hospital follow-up transported off site for care at a community hospital.
of patients categorized as not needing an ambulance using a set We describe the use of a set of treat-and-release direc- of emergency medical technician protocols. Prehosp Emerg Care.
tives for mild, uncomplicated illnesses or injuries at a single-day mass gathering. Further study is needed to 10. Goldberg RJ, Zautke JL, Konigsberg MD, et al. A review of pre- hospital care litigation in a large metropolitan EMS system. Ann evaluate the safety and efficacy of such protocols.
The authors acknowledge the editorial assistance of Dr. Russell 11. Lerner BE, Billitier AJ IV, Lance DR, Janicke DM, Teuscher JA. Can MacDonald, MD, MPH. In addition, they thank Deputy Chief Alan paramedics safely treat and discharge hypoglycemic patients in Craig, Rose Baynham, and Toronto EMS paramedics for organizing the field? Am J Emerg Med. 2003;21:115–20.
and providing care for over 450,000 concert patrons.
12. Mattila EM, Kuisma MJ, Sund KP, Voipio-Pulkki LM. Out of hospital hypoglycaemia is safely and cost-effectively treated byparamedics. Eur J Emerg Med. 2004;11:70–4.
13. Mechem CC, Kreshak AA, Barger J, Shofer FS. The short-term outcome of hypoglycemic diabetic patients who refuse ambu-lance transport after out-of-hospital therapy. Acad Emerg Med.
1. Grange JT, Baumann GW, Vaezazizi R. On-site physicians reduce ambulance transports at mass gatherings. Prehosp Emerg Care.
14. Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D. Prehospital hy- poglycemia: the safety of not transporting treated patients. Pre- 2. Furst IM, S´andor GKB. Analysis of a medical tent at the Toronto Caribana Parade. Prehosp Emerg Care. 2002;6:199–203.
The Special-events Medical Directives Prehospital Administration of
Dimenhydrinate (Gravol)
• Concomitant use of tranquilizers or sedatives, in- When the following conditions exist, a paramedic mayadminister dimenhydrinate (Gravol) for nausea and/orvomiting.
1. Administer dimenhydrinate according to the fol-
Systolic blood pressure >100 and <180 mm Hg • 6–12 years 25 mg per os
>12 years 50 mg per os
• Allergy or sensitivity to dimenhydrinate 2. Advise the patient not to drive or operate heavy ma- • Continued or repeated vomiting (more than two 3. Advise the patient to seek medical care if repeated • Patient has previously received or taken dimen- vomiting occurs or the patient becomes thirsty or hydrinate within the previous four hours prior to 4. The patients may be released from care after treat- ment if he or she continues to have normal mental • Signs suggestive of a heat-related illness TREAT-AND-RELEASE MEDICAL DIRECTIVES AT MASS GATHERINGS Prehospital use of Polymyxin B
1. Administer acetaminophen (Tylenol) 650 mg per os
When the following conditions exist, an emergency 2. All attempts must be made to ensure that the pa- medical technician or paramedic may use polymyxin tient is transported to hospital if headache persists B (Polysporin) for minor wounds and abrasions.
or does not conform to the patient’s usual pattern, orif serious musculoskeletal injury is suspected (e.g.,fracture). If the patient ultimately refuses transport, Conditions
appropriate procedures must be followed.
3. The patient may be released from care after treat- ment if he or she continues to have normal mentalstatus and vital signs.
Prehospital Administration of
• Allergy or sensitivity to polymyxin B Diphenhydramine (Benadryl R )
When the following conditions exist, a paramedic may Procedure
administer diphenhydramine (Benadryl R ) for allergic rhinitis (“hay fever”-type) symptoms or isolated hives 2. Place a small quantity of polymyxin B (Polysporin) onto an appropriate dressing and apply it to the af-fected area.
• Instruct the patient to seek medical care if the affected area shows signs of infection, requires • Symptoms consistent with allergic rhinitis; e.g.: sutures, or requires d´ebridement beyond simple • Isolated hives without other signs of anaphylaxis • Advise the patient to follow up with his or her • Systolic blood pressure >100 AND <180 mmHg primary health care provider to ensure that his or Contraindications
Prehospital Administration of
Allergy or sensitivity to diphenhydramine.
• Evidence of wheezing, or other signs of anaphylaxis Acetaminophen (Tylenol)
• Patient has previously received or taken antihis- When the following conditions exist, a paramedic tamines within the previous 4 hours prior to contact.
may administer acetaminophen (Tylenol) for un- • Concomitant use of tranquilizers or sedatives, in- complicated headaches and minor musculoskeletal Precautions
• If the patient presents with signs and symptoms consistent with anaphylaxis, they should be treated • Headache must conform to the patient’s usual pat- according to the appropriate medical directive and tern. Note: If there is any deviation from a patient’s normal headache pattern (e.g., sudden onset, changein mental status, transient neurologic deficits), Procedure
acetaminophen must be withheld and transportoffered.
1. Administer diphenhydramine 50 mg per os
2. Advise patient not to drive or operate heavy
• The patient must be >12 years of age 3. Advise patient to seek medical care if short of breath, wheezy, unable to swallow, feels faint or experienceshives or facial or tongue swelling.
4. Patients may be released from care after treatment Contraindications
if they continue to have normal mental status, vital • Allergy or sensitivity to acetaminophen signs, and show no signs and symptoms of anaphy-



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Comorbidity and PCCs Cynthia M. Boyd, MD MPH Assistant Professor of Medicine and Health Policy and ManagementJohns Hopkins University Clinical Practice Guidelines (CPGs) •Developed for management of a specific •How do they apply to people with multiple Copyright 2006 The Johns Hopkins University Does CPG Address Older Patients with Multiple Guideline Does CPG mention tr

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