Event medicine is an all-encompassing term that embraces the provision of medical care across all derivatives of similar practice. This includes mass gatherings at sporting events, large crowds at festivals, outdoor entertainment events, and within stadiums accommodating either sport or music events. Therefore, it was used as such in the current article.
Such large-scale events, are considered as being heterogenous in the context of their size, duration, type of event, crowd-behaviour-linked recreational substance use and environmental factors (Schwartz et al, 2015). Therefore, they pose complex challenges in medical provision. In these prehospital environments, medical services are generally provided by a broad range of clinicians, including paramedics, doctors, nurses, and first responders (Alinier et al, 2022).
Event medicine was brought into the spotlight in the UK back in 1989, with the tragic incident of the Hillsborough Stadium Disaster. The following year, the Taylor Report was published by The Rt Hon Lord Justice Taylor (1990) who, among his recommendations, advocated for baseline figures for future medical staffing at sports events, which continue to inform and influence current event safety documents in which event medicine guidelines are published.
For events held at sports stadiums, the Sports Ground Safety Authority (SGSA) (2018) guide to safety at sports grounds (colloquially known as the ‘Green Guide’) is referred to. The point of reference for events such as large music concerts or outdoor festivals is the purple guide to health, safety and welfare at outdoor events produced by the Events Industry Forum (EIF) (2023).
Both regulatory guideline documents are supported by the statutory body, the Health and Safety Executive (HSE), in their overarching role of ensuring that health and safety legislation at events is enforced by local authorities. This occurs via non-statutory groups of representatives providing a multi-agency approach in the form of safety advisory groups (SAGs) (HSE, 2024).
In considering event medicine and its existing evidence base for practice, the view expressed by Arbon (2007) is that current mass gathering medical data are too descriptive and lack critical analysis. Arbon (2007) suggests that applying research frameworks to this area of medicine will enable more science-based practice. Likewise, a decade later, Smith et al (2017) offers a similar perspective, noting that examples of event medicine best practice are frequently anecdotal and originate from clinicians who provide medical cover at such events (Smith et al, 2017). Spaepen et al (2023) concluded that the literature contains no standards for medical planning at mass gathering events over the last 20 years.
Hence, given that the origins of event medicine guidelines date back over 30 years, that large-scale events form an important part of the UK's entertainment and sporting culture, and that the complexity of medicine at such events remains an undetermined domain, the present article intends to analyse and clarify the status of research articles written about the intricacies of event medicine.
Methods
The aim of the current study is to explore, analyse and understand the current literature-based evidence regarding event medicine provision at large-scale events and, subsequently, to identify collective themes and areas for future research, prompt clinician reflective practice, and inform the professional evidence base around event medicine planning, management, service provision (collectively considered as ‘operational practice’). A literature search was undertaken between January and April 2024, using the Medline, PubMed, and Google Scholar databases. The search terms used were ‘event medicine’, ‘mass gathering medicine’, stadium medicine’, and ‘crowd medicine’.
The review aimed to consider the subject of ‘event medicine’ in its broadest sense. Therefore, the inclusion criteria included articles on sports events, music events, outdoor festivals, religious events, both indoor and outdoor stadiums, and stadium disasters.
Articles that were more than 20 years old (published prior to January 2004) were excluded, since they were outdated in terms of their themes or event industry perspectives. Parameters searched included English language and full-text accessible articles.
The search returned an average of 18 600 articles, 480 of which were considered to be pertinent, and 32 of which were considered suitable for final inclusion in the literature review (Figure 1).
PRISMA flow chart demonstrating process of article selection for inclusion in review
Data from the 32 articles were analysed using the six stages of thematic analysis proposed by Braun and Clarke (2006). These include: familiarisation with the data; generation of initial codes; search for themes; review of themes; definition of naming of themes; and writing up.
Results
The five themes below emerged from the articles written about event medicine in the present literature review, all of which are further explored in the Discussion section:
Articles included originated from Europe, North America, Southern Africa, and Asia (Oceania/Middle East), across a variety of events consisting of outdoor music festivals, football stadiums, motorsport racing, baseball stadiums, US football stadiums, athletic meetings and electronic dance events.
Discussion
Patient presentations
The evidence suggests that patient presentations are clinically split, with researchers categorising presenting problems into broad groupings.
English football stadiums
Three studies of medical services at English football stadiums provide comparative data when considering the variance in medical attendances.
Over the course of the most recent study, Leary et al (2017) explains that 57.2% of episodes were categorised as ‘medical’ and 42.3% categorised as ‘trauma’. Between 2002 and 2008, 62.6% of episodes of care were characterised as ‘medical’, with the remaining 37.4% being classed as ‘trauma’. From 2009 to 2015, 52.7% of episodes of care were categorised as ‘medical’ and 47.3% as ‘trauma’.
Another study looked at data covering nine seasons (830 patient presentations), which also categorised these presentations into broad groupings as part of its methodological analysis: 512 new injuries and trauma (62%), and 318 medical (38%) (Bird, 2016).
Both Leary et al (2017) and Bhangu et al (2009) refer to the notable proportion of stadium matchday staff who utilised medical services for the treatment of injuries or existing medical conditions.
In an earlier English football stadium study, Bhangu et al (2009) reports 41% as having minor trauma, 27% as experiencing new medical conditions, and the remaining 32% presenting with either the exacerbation of, or the opportunistic presentation of, existing illnesses.
Other outdoor events
Moving away from football stadiums to a large-scale outdoor music festival, a study of medical attendances at The Glastonbury Festival in the UK presented quantitative data showing that virtually one-half of all diagnoses were illness-related (45%), followed by injury (39%), and environmental causes (13%). The lowest percentage of presentations (3%) were related either to mental health, or recorded as ‘no abnormality detected’, or ‘unclassifiable’ (Bennett and Cottrell, 2024).
Another comparative large-scale outdoor event is the New York State Fair in the US. A study of 5 years of data concluded that the three headline reasons for patient presentation were dehydration/heat-related illness (11.4 %), abrasion/laceration (10.6%), and fall-related injury (10.2%) (Grant et al, 2012).
An alternative sports stadium perspective from Japan analysed the incidence of medical events at a professional baseball stadium. The study splits spectator presentations to medical personnel into two main categories: ‘trauma’ (51%) and ‘illness’ (44%), with the main causes of trauma being ball injuries, followed by trips and falls. The authors noted an increased number of incidents connected to night games, either before the start or towards the end of the games. This implies that conditions in the stadium during the evening may have been a factor linked to presentations (Ishikawa et al, 2007).
Factors affecting presentation
When considering variable factors that influence presentation rates, it has been noted that there is an association between raised temperature/humidity (warm weather) and increased presentation rates at mass events (Baird et al, 2010). Hence, relative consideration needs to be factored in to any future predictive models for event medical planning. Other factors identified as being connected with increased patient presentations at mass gatherings include outside or unbounded venues, the availability of free water, no climate control, seat–standing ratio and an increased heat index (Locoh-Donou et al, 2016).
As well as documenting some of the environmental factors that influence patient presentations, the evidence also point towards logistical reasons for attendees requesting medical support when attending a large-scale event. At a football stadium in Durban, South Africa, patients presenting with an exacerbation of asthma or cardiac episodes (pre-existing medical conditions) raised an unforeseen issue, which Hardcastle et al (2010) related to logistical arrangements of a no-drive security zone around the footprint of the stadium; this meant that supporters were required to walk a minimum of 3 km to get to the venue.
Medical resource skill mix
In their comprehensive review of medical services at an English football league stadium, Leary et al (2017) expressed that the existing framework for guidance on crowd medical services remained largely based on findings from over 25 years ago. In this same time period, the authors note that clinical roles of healthcare professionals had evolved substantially. Therefore, guidance needs to be considered in the current context of event medicine practices and resources.
More specifically, when considering the role of doctors in the UK at large-scale sporting events, guidance around doctors' duties has remained somewhat broad-based and unchanged over the last three decades, highlighting that the overall directives for medical cover can be considered as limited and creates ambiguity with respect to the role of event doctors (Smith et al, 2017).
A perspective from the US is offered in a review of medical events at the Gillette Stadium (Massachusetts) (Goldberg et al, 2023), in which medical cover is provided by predominantly healthcare professionals, including two-person teams consisting of a trauma physician and trauma nurse. Medical rooms are staffed by emergency medical service professionals (paramedics), with private ambulances on site to provide conveyance to hospital.
Likewise, an article focusing on the FIFA 2010 Soccer World Cup in South Africa, specifically The Moses Mabhida Stadium in Durban, discussed the use of a medical team made up of doctors, paramedics, nurses, and ambulance crews, which for skill-mix purposes, they categorised as clinically competent at delivering either advanced life support (ALS), intermediate life support (ILS) or basic life support (BLS) (Hardcastle et al, 2010). Use of this combination of disciplines was replicated in the FIFA World Cup 2022 in Qatar, to enable appropriate medical provision across eight stadia, multiple team hotels, fan zones and training facilities (Alinier, 2022).
On this theme of clinical capabilities, Schwartz et al (2015) advised that the skill set of attending clinicians is reflective of the medical care likely to be required based on previous clinical data sets. This proposed concept is supported by a study of a rave music event that took place across a 5-year period. It suggested that having nurses and paramedics on the medical team provided particular skill sets related to event-specific injuries, health education, advanced life support and knowledge of infection-control practices (Krul et al, 2012).
In addition to the expected clinical workload of any large-scale event, the literature highlights the importance of event medical teams being prepared and suitably experienced for a major incident. This refers to the use of clinician-led medical services with the ability to manage the response to such incidents, through adequate professional preparedness and training (Soomaroo and Murray, 2012).
Finally, broader ambiguity can be seen in the data presented from across football stadiums in the Netherlands. In a research article by van de Stadt and Umans (2009), medical response teams are described as consisting of varying clinicians including first aiders, emergency service personnel, emergency nurses and cardiac nurses. The authors noted a clear inconsistency of medical staffing levels relative to stadium attendance numbers across all the stadiums reviewed (van de Stadt and Umans, 2009).
Predictive modelling
A shared perspective on how to predict event-medicine activity is proposed across a few studies, which look at retrospective data for a certain event, or review previously documented evidence from similar events, which can collectively inform and improve the planning and provision of healthcare services at large-scale events (Arbon et al, 2001; Zeitz et al, 2005; Scwartz et al, 2015). As such, there is an evolving body of evidence suggestive of retrospective analysis of previous event data to predict event-medicine requirements at future similar events.
Widening out the discussion around predictive modelling, other studies have sought to determine a complex mix of factors that influence event-medicine modelling. A retrospective study across 6 years at a US football and concert stadium identified key variants for planning future medical cover at stadium events. These included the mutability of presenting complaints; environmental factors; and the event type, including the demographic of those attending (Goldberg et al, 2018).
Another research article looking at the event characteristics of large-scale events (attendees over 1000 people) in the US concluded that key predictive factors included alcohol and drug use, as well as the aforementioned weather conditions and event type (Moore et al, 2011). Supporting the perspective that drug and/or alcohol intoxication need to be considered as a key aspect of predictive modelling, a literature-based study found that substance use and/or intoxication is likely to create an additional workload on medical services at events, particularly at music festivals (Bullock et al, 2018). Therefore, a combination of multiple factors is considered significant to event-medicine modelling.
A supplementary view is offered in a couple studies, where crowd activity is considered in terms of its relationship with event planning. In a study of three mass-gathering events, Hutton et al (2018) sought to understand the audience ‘motivations’. They explained how understanding cohort behaviour, or certain population risks/hazards, may facilitate improved awareness among event planners and emergency medical services of audience behaviour, as well as an informed insight into potential medical emergencies when preparing for various types of events. Furthermore, Zeitz et al's (2012) literature review of crowd behaviour at mass gatherings highlighted the importance of understanding the dynamics of crowd behaviour in relation to event planning and influencing crowd-management outcomes.
Although there is a small but evolving body of evidence around developing predictive models for event planners, there remains no widespread agreement around the factors that are most predictive for event-medicine planning (Moore et al, 2011).
Transfer-to-hospital rates
The 2005 World Championship Games in Athletics in Helsinki, Finland, was the basis of a multi-layered study, which showed a 5.9% increase in local ambulance services transferring patients to hospital. In it, Hiltunnen et al (2007) raised the question of whether or not such effects on local healthcare services are factored into large-scale event planning.
Considering how transfer-to-hospital rates might be reduced or prevented, articles from Canada, the US and South Africa, discuss how having healthcare professionals as part of the event workforce can result in this positive outcome. Firstly, the presence of a higher level-of-care model (HLC) (as opposed to first aid only) at a 2-day electronic dance music event reduced transfer-to-hospital rates by approximately 75%, thus reducing impact on local healthcare systems and emergency health resources (Lund and Turrris, 2015).
A further single-site study at a US motorsport racetrack concluded that having physicians at the racetrack to provide medical care for spectators significantly reduces the number of patients needing to be referred to hospital and subsequently conveyed by ambulance (Grange et al, 2003). Within the ‘term’ physician, however, they include doctor, paramedic, and nurse. In another study looking at the 2010 (soccer) World Cup, Hardcastle et al (2010) note the value of having doctors and nurses as part of the medical team, emphasising a reduction in the number of transfers to hospital where this higher level of medical skill was present.
A literature review carried out by Ranse et al (2017) concluded that there is minimal research considering the effect of mass gatherings on external health services or locality ambulance services. This further highlights the need for event clinicians to consider the medical outcomes of such events on the wider healthcare community.
Acute cardiac events
Picked up in a smaller number of studies, acute cardiac events could be included as a sub-theme of patient presentations. However, it is considered independently because of its traumatic nature and pertinent effect at a large-scale event.
Highlighting the elevated risk for sudden cardiac arrest in sports stadiums to both athletes and spectators, both Bassi et al (2023) and Goldberg et al (2023) describe that risk factors such as physical and emotional stress (e.g. when attending high-pressure sports events), and meteorological conditions, increase the potential risk of such an occurrence.
The importance of having emergency response protocols, including automated external defibrillators (AEDs) in place at large sport venues cannot be overlooked, as was identified by van de Sandt and Umans (2009) in their study from the Netherlands looking at the incidence rate of acute cardiac events in large sports stadiums. This insight is echoed by Bassi et al (2023) and Goldberg et al (2023) who not only mention the importance of AED availability, but also stress the importance of staff training being a part of emergency response preparedness. Gianni et al (2024) explained how Italian law mandating AEDs in all sports venues has shown an increased rate of successful cardiac arrest outcomes.
Recommendations
Based on the findings of this literature review, the author compiled the following recommendations for prehospital clinicians involved in event medical practice:
Conclusion
Event medicine is a developing specialty within prehospital care. This literature review has shown that it is under-researched and, as such, there is a significant theory-practice gap in relation to the evidence base that supports large-event medical service planning, provision, and application.
The evidence demonstrates the complex dynamics that underpin event medicine, focusing on the themes of patient presentation, medical resource skill mix, predictive modelling, transfer-to-hospital rates, and acute cardiac events.
The literature suggests that event-medicine clinicians need to consider developing evidence-based models to provide more consistent and substantive standards of care to unwell and injured event attendees. Such standards should limit the effects of medical need on associated locality health services, and have pragmatic plans in place to respond to and manage clinical emergencies and incidents.
Event-medicine clinicians need to be cognisant of their professional skill sets, and determine how these intermesh, as well as challenge existing guidelines on the conceptual roles undertaken by clinicians within this sphere of prehospital care.
It is equally evident that clinicians practising within this environment can learn a lot from past event healthcare data – from minor traumatic injuries resulting from slips, trips and falls, to managing cardiac arrests, and being aware of AED availability, as well as the importance of medical personnel resuscitation training and education.
Additionally, consistent quantitative metrics for measuring clinical care provision need to be widely adopted and critically analysed to inform evolving core standards, and positively influence evidence-based practice of event-medicine clinicians at future large-scale events.