Event medicine

Doctors are asked to provide medical cover at increasing numbers of events such as football matches, marathons, air shows, and music festivals. Neil Dignon and Stephen Hearns explain the hard work behind the glamour of event medicine

Medical services at events are mainly concerned with assessing and treating minor injuries and medical conditions. This allows people to return to the event with minimal delay and minimises any overload on the local permanent medical facilities. Medical services also have a role in resuscitating seriously ill and injured patients on site and ensuring safe transfer to hospital. In the event of mass casualties the event doctor has a key role in major incident management. Guidelines for providing medical services at events are described in The Event Safety Guide and Guide to Safety at Sports Grounds.^{1 2}

Medical conditions encountered
Major events often generate crowds as large as the population of a moderately sized town. Medical problems are not simply likely but inevitable. The frequency and type of medical conditions encountered varies according to the type of event and the crowd profile.

Exacerbations of pre-existing medical problems of crowd members (such as asthma, epilepsy, and diabetes) are common. Traumatic injuries resulting from falls and assaults are also common. There may be specific risks associated with the event itself, such as exhaustion and hypothermia in runners during a marathon. Crowds at large outdoor musical events may experience problems due to the vagaries of the weather, from hypothermia to heat exhaustion. Drugs and alcohol are an intrinsic part of the festival experience for many people. Some will be experimenting with drugs for the first time, and psychiatric and psychological problems are common, often precipitated by the use of illicit substances.

Although major problems are unlikely, one only has to think of the tragedy at Hillsborough stadium, with 95 dead and 200 injured,³ or the recent Roskilde music festival (Denmark, July 2000), with nine dead from traumatic asphyxia, to appreciate the potential for emergencies requiring highly skilled medical care on site.

Event doctors have to be capable of dealing with presentations from a wide clinical spectrum. Serious incidents are rare, but we have both been involved in cases requiring advanced resuscitation techniques on site, including chest drain insertion and rapid sequence induction of anaesthesia.

Experience and training
The qualifications and experience of doctors working at events are varied. Several specific types of event have minimum training requirements for doctors, but these vary between organisations. Guidelines published by the Health and Safety Executive state that a medical officer should have experience of dealing with emergencies in prehospital or emergency environments within the previous two years.¹ They should have attended a course in prehospital emergency care and should have completed a course in major incident management. The Guide to Safety at Sports Grounds states that crowd doctors must be trained and experienced in immediate care.²

The Football Association (FA) now recommends that newly recruited crowd doctors hold the diploma in immediate care from the Royal College of Surgeons of Edinburgh (personal communication, August 2001). These requirements do not extend to those doctors already active as FA crowd doctors. It is now also mandatory for crowd doctors to attend a crowd doctor course run by the FA.

The BMA suggests that doctors at sports events should ensure that they have knowledge of resuscitation procedures, airway maintenance, and spinal fracture immobilisation and be able to treat anaphylaxis correctly.⁴ From our experience, we recommend that event doctors have completed courses in advanced life support, advanced trauma life support, and paediatric life support. Acquisition and maintenance of skills in airway management and emergency medicine are also advisable. Completion of a course in the management of major incidents and familiarity with the local plan are essential.

As emergency doctors, we have found that medical cover for large events ideally involves a medical team with a variety of specialist skills, including anaesthetists and general practitioners, provided they have the core skills suggested above. Each event should have a senior medical officer responsible for the overall medical management of the event. This doctor will also assume the role of medi-cal incident officer if a major incident occurs.

You must be familiar with communications protocols and equipment at events. We have found that mobile phones are often unreliable in large crowds. The event should have written radio protocols and chains of communication. Training and experience in the use of two way radios is indispensable.

Documentation must be scrupulous, and must not slip below those standards expected in your usual practice. It is useful to prepare your own printed patient documentation forms. We both have worked at events where we were given pocket notebooks from a local stationers for patient records.

Pay
Rates of pay are variable, from £30 per hour, to much higher rates at new year's eve celebrations. Many event medical staff work for free. Some take payment in kind, such as doctors providing cover for smaller sports clubs in return for a free seat in the stand. There are often additional fringe benefits such as free event tickets, backstage passes, or the use of hospitality facilities at the end of a shift.

Liability and indemnity insurance
In view of the potential risks in providing prehospital medical cover for large groups of people, it is essential that every event medical officer has adequate indemnity insurance for malpractice. The major medical defence societies can provide their members with indemnity cover for this type of work. Most allow non-NHS earnings from activities such as event medicine of £5000-7000 a year with basic premiums (personal communications, Medical Defence Union, Medical Protection Society, Medical and Dental Defence Union of Scotland, August 2001). Doctors should discuss their event medical activities with their defence organisation before the event.

Staff working at events face a possible risk of personal injury, such as from assault or needle stick injury. Doctors must ensure that they have adequate personal injury insurance, especially if they are working as independent contractors to an event organiser.

Pros and cons of event medicine
Event medicine is often exciting and glamorous. In addition to the thrills of being stadium doctor for the team you've supported since childhood or watching your favourite band from the side of the stage, it offers a unique insight into the "behind the scenes" activity that ensures an event runs smoothly and safely.

Your working relationship with the emergency services, particularly the ambulance service, is closer than in everyday practice. You have the opportunity to work alongside and liaise with the many groups that ensure safety at an event, including local government agencies, police, fire service, promoters, stewards, and first aiders. This involvement is at the planning and risk assessment level and also during the event itself. There can be great satisfaction in knowing that you have contributed to a hugely enjoyable experience for a large number of people.

However, you should also be aware of the difficulties inherent in event medicine. You must exercise personal discipline and remember that the main reason you are there is to provide medical care. It is easy to be distracted by activity on the field or on stage.

You have to be prepared to adapt to the limitations imposed by the prehospital environment. The monitoring and investigative facilities we are used to in hospital are usually lacking. Assessment of patients is also often difficult because of noise. You require sound clinical judgment in deciding who is fit and safe to allow to return to an event. Patients may be intoxicated or reluctant to leave an event that they have paid to attend. This cannot be allowed to influence clinical decision making.

Equipment may be provided by the event organiser. This must be checked before the event, especially resuscitation equipment. Often the responsibility lies with you to provide adequate equipment and drugs. This can be expensive and time consuming. Appropriate clothing and personal protective equipment suitable for outdoor work are also necessary.

What about my career?
With careful planning, you can fit in time for event cover with most careers. Sports events are usually at weekends and are relatively brief in duration. Major events such as music festivals are planned long in advance. This allows most practitioners to combine full time employment with involvement in events.

In our experience, an interest in event medicine is a useful addition to a curriculum vitae and often a talking point in interviews. You need to have initiative and diplomacy to work in a prehospital environment, and it helps you to develop clinical and communication skills.

If your experience and preparation are adequate then event medicine is hugely enjoyable.

Neil Dignon, specialist registrar in emergency medicine, Victoria Infirmary, Glasgow

Stephen Hearns, specialist registrar in emergency medicine, Emergency Department, Monklands Hospital, Monkscourt, Airdrie
Email: stephen@frontlinemedics.com

Stephen Hearns is director of FrontlineMedics.com, a company that provides medical cover for musical and sporting events.

studentBMJ 2002;10:1-44 February ISSN 0966-6494

1. Health and Safety Executive. The event safety guide. London: Stationery Office, 1999.
2. Guide to safety at sports grounds. 4th ed. London: Stationery Office, 1997.
3. The Hillsborough stadium disaster final report. London: HMSO, 1990. (Taylor report.)
4. British Medical Association. Doctor's assistance to sports clubs and sporting events. www. bma.org.uk.