University Hospitals of Cleveland's Manager of EMS and Community Outreach, Laura Frost, RN joins the full crew to discuss event medicine planning and execution. From small community picnics to high school graduations to large national events, planning is the key. This month's discussion emphasizes pre-event assessment, logistical planning and patient care.
Prehospital Paradigm Podcast
Event Medicine for EMS Pre-Assessment, Execution and Lessons Learned, Part 1
[MUSIC] Hey, everybody. Welcome back to Pre-Ospill Paradigm Podcast. I'm Scott Wildenheim. I've got my regular crew, Ray Pace. Thanks for finally getting here. We're late in the day because somebody had chief duties to do and got Dr. John Hill across from me and our special guest, but part of our regular team here at UH is Laura Frost, and she's our manager of community outreach stuff. The show notes here reflect something else, but we're going to manage your VMS and community outreach. Of course, Dr. Hill's over there putting questionable things in the show notes for today. Anyway, today, I want to talk about event medicine. And really from the perspective of the setup, the logistics, the pre-planning, the stuff that needs to go into that, for any department, whether you're talking about a community level, get together with just your local population or you're talking, in my case, I was part of planning for something as large as the RNC when they came to Cleveland. So there's a wide variety of considerations that need to go in there. I want to talk about some of those things. So there's an off-air, you said, talked about proper planning and piss poor performance. This is one of those things that can really bite you if you don't spend a little bit of time. Of course, depending on the size of the event, a lot of time, planning it out. And you have a lot to do with the Canfield Fair. Yes. So tell us a little bit about what's gone on there. And that's, again, just off-air. What was the second largest? It's the second largest fair in the state of Ohio. Second largest in the state of Ohio, so. And it's six days long. It's all week. All week. Over a holiday weekend. It's usually the end of August and December. So it's always hot. Very hot. How many people do they see there? On Saturday, Sunday, Monday, about 150,000 people come through each day. Yeah, there are large concerts at night. You know, big country singers. They draw. Track your pool. Track your pool's huge. Pretty dim lotion. You're already up there, too. Yep. Yep. So a ton of a lot of cars. It's fun. A lot of car fires. Yeah, car fires, sure. And what kind of things in your jurisdiction do you have in the event medicine space that-- For me, we have an event that recently moved. We used to have an air show. Smaller, we have a grass field airstrip in our township. So they would have all different types of planes. We called it wings and wheels. That's since moved locations because they outgrew the current location. We partner with the Air Base when they do have the larger air show for that, a lot of logistics, long period of time. Tons of people. It's usually extremely hot. Those are some of the big ones that I could think of. We help with the Trumbull County Fair. We assist there. But I mean, even to your point and the opening point about everyone's town, whether you're a city, a township, a village, whatever you are, it could be high school graduation. It could be a huge event. One of the things that we do is we pre-playing our high school graduation a little bit. You have all of your bleachers at the football field that are completely full. What's the temperature? What's the age of those attendees? Stuff like that. And then in my past role at Portage, we used to do some stuff with Ken State graduation. So it could really be any large, just a general event, whether graduation, some type of festival. It just could be any of those things. Fair. You name it. And we just came off recently here, the Cleveland Marathon. This was actually the first year I didn't do anything. I usually run communications, EMS communications for that every year. This was the first year I didn't do anything. After my 10th year, I figured I'd take the 10th year off. And then I'd start my next 10 years to do it for me. But anyways, came off of that. Oh, I forgot 4th of July. That's our thing. Totally spaced on that. I apologize. 4th of July parade and our township is huge. That's a big huge. Oh, yeah. Well, and we'll talk about this for planning. And you have to have access too, right? So if you're talking about parade around, you've got a whole typically main drag that's closed. You're probably splitting your township or your area into two separate places. And how are you going to get around that, or get through it, or stage so that way you can cover where you need to cover it. OK, we just want to start with that. I mean, if you open the door, let's talk about the access. So one of the many things you need to consider when you're getting ready for these things is not only is how are you going to get equipment apparatus in, but if you're staging there, how you're going to get patients out. So I'll start with my experience with the RNC, where any of our vehicles coming into that space was heavily scrutinized by Secret Service, FBI. So there wasn't just come and go as you please. There wasn't the copy that you knew from your township or from your jurisdiction. You'd be like, hey, George, hey, they let you drive in. We had to go down to the stadium, be cleared by bomb dogs. And then the trucks had to be escorted back up. So actually transporting patients was almost a problem in that particular case. So we had ambulances in the hot zone and that inner circle. And we had previously agreed that we would only transport out of that if it was cardiac arrest or STEMI or otherwise. We would have ambulances that were posted on the periphery come to that margin. And we would actually do a patient handoff. So care provided on scene and in our particular case, what we were servicing there was the Convention Center. We were bringing them out right to that periphery and then we were taking them out. Sometimes a couple of the patients, we took out and we had the luxury of having an ATV, having a 6x6 took them out, put them in the ambulance. And then another couple of times, actually, into the ambulance, ambulance the ambulance and then took them off. So they didn't have to go through all of that. But even something is even something more regional, you said a parade, right? If that's all jammed up, you've got to figure out how you can get out of that depending on geography and what you can accomplish in the space that you have, in the anticipated footprint. So anything else on access that comes to your eyes and mind? No, that's huge. Access with parades, so we have to think about that. That will decipher our township, essentially into North and South. We're going through the main west to east thoroughfare. So you're going to tie it up. And then now, because of recent attacks and because of some of the things that have happened, whether they're foreign or domestic, not the RNC, use the Cleveland Marathon, excuse me, for example, or any type of street fare or any type of parade. Now, what's parked at every intersection? Two snowplows with a dumphead full of sand or stone, or some item. And those drivers usually aren't sitting in that truck. So their only goal is, well, I need to park all these trucks here to block the main intersections. So no one can drive into that crowd of people and hurt them. But now, that's another obstacle. Access is another problem. So one of the things that we had talked about for this year is we will not put all of our apparatus into the parade. We will have a north and a south staging crew, and that's the way it's going to go. But even little logistics that we cover and pre-planning prior to the parade is before everybody even gets into the trucks, we have staff members, families, we have their children. Usually, we have some sort of a guest that is going to ride. And you have to discuss, hey, if we receive this type of a call, if you get a fire in the middle of this parade, we're going to stop wherever we're at. And then we're going to get everybody safely out of the vehicle. And then we're all going to get back into the vehicle and then respond to the emergency. And not every exit, essentially, is blocked with a snow plow truck. Some of them we've had police cars, and they're standing by them so we can use those as more of a mobile object. Yeah, but it's just something that simple. If you didn't plan that, and you're in your normal 4th of July parade, and there's four kids in the back of your engine, do you have a parent for those children to get them out? All those type of little logistics that I know they seem very small. They're small until the tone's hit, then you've got to handle it. Yeah, now it's a problem. I think back to the village I grew up in, the fireworks were in the park every 4th of July. There was one way in and one way out of that. Yeah. As I think through it now, I do things real differently today. If you ask me to do it today, then, well, 25 years ago, where's the ambulance park way around back? If somebody crashed a car or something in the front, there was a shooting. There was a gas exit. That's for some reason, all that was jammed up. We weren't going anywhere. No, it's going to bottle neck. It's just going to bottle neck, right? If everybody's fleeing, they'll say the worst case scenario, active shooter, or something like that. Bomb scare or whatnot, and they're not going to say, "Oh, let the ambulance buy." They're all going to be fleeing him, and like you said, bottle necking up. And I think it goes into the design of your event. It's kind of Laura's dealt with the Canfield Fair, how you talked about, we have these ambulances in the hot zone. There is one or two ambulances next to the first aid station in the hot zone, and then they're using UTVs to go out, because it's easier to leave the ambulances on the outside perimeter. When you have 150,000 people in this small area, it's hard to get to the patient, and that's something we've run into. As you have this person who needs help, they fail whatever it is. How do we get to them, but also take our equipment and everything we need, but then to safely bring them back to us? So we don't actually take the ambulances inside the fairgrounds, unless there's a cardiac arrest or some type of big, significant event. Otherwise, it's all the gators. Go get the patient and then make the determination to either come to us or if they need to go directly out. - I imagine if you had a limited budget or whatnot, in worst case scenario, you could improvise something, right? You don't find somebody's pickup truck, or not that I would be Bahan, I'm across the, but I mean, now everybody has the luxury of a gator or something else, right? - Right. - But to highlight your access point there, I can remember a concert event that we were doing, and similar process, we had a kind of on the periphery, we had a trailer setup, which was our field hospital, right? And then we would send out, we had two gators that were running out. And of course, it was incredibly hot day, and of course, it was incredibly humid day, and everybody was drinking, right? So we had the trifecta, and we'd watch people go down, you hear the radio call, and then the gator would, and you would, we were just up elevator enough, we were kind of looking down, and we would watch as, you know, it would just take forever for the gator to work through the crowd. I'm like, I know he needs to get there. I probably could walk there faster, right? Yeah, and that's eventually what we were doing, is we would send the gator out. He's like a chase person almost. Right, they were grabbing a bag and just walking out 'cause it was faster. You know, you think you can drive there and back, but turns out a bunch of drunk people flying all over the place give-- Lights and sirens, they don't move, they don't hear it, yeah. They don't, and again, we were up close to the stage, it was loud, they probably could not legitimately hear it as well, and that's-- But there might be nowhere to go, if you're that crammed in, that's the bus. That's much, yeah, it's true. Yeah, my big ambulance down a narrow pathway, essentially, as we're talking about, like a festival down on a street, but like fairgrounds, it's hard to get big vehicles there, and sometimes ATVs make way with our senses or what we do at Canfield. Right, yeah, but eventually, that's what we were doing. We were just sending humans out, and they were getting there first, by the time they wiggled the ATV, and that's what we re-repatriated the-- And generally, I think they could get back faster once everybody knew that something was going on, but just things to keep in mind from an access perspective. And our routes were constantly changing at the Canfield Fair, if they have an event in the infield, or something, you can't go that way to get your ambulance out, so you constantly had to know, what are they having during concerts? You can't go this route, you have to go this route, or changing that, and then also thinking about helicopter access, if we would need to fly someone out where your landing zone's making sure flight team has those ahead of time, because in the middle of pure chaos, no one's like, oh, we have to call a flight team and give them the exact coordinates to land, you know, you're-- - And set up a landing zone to get out, but you're flying and all those things. - So making sure that ahead of time we set that up, this is zone one, two, and three, and flight team has those pre-programmed, so just to make sure that we think of every option. - From the aeromautical standpoint, that's a really good point, right? To have that set up, have those coordinates already. - Just tell them you're going to one, two, or three, and they know where they're going. - Exactly, right, yep. So your point about, as things evolve and as things change, you know, the dissemination of information there, of course, that plays into communications and essentially an incident command structure like we would have on any other scene, right? You know, hey, this route has changed and how that gets communicated. It's been my observation that a lot of events try to use simplex talk around channels for, rather than their main repeated channel on their radio, and oftentimes it's smaller events. Oftentimes, that is not practiced ahead of time and there's a bunch of gaps in radio coverage that there's like, oh, we'll just use a talk around channel, we'll talk radio to radio, but turns out, you know, opposite sides, once you put a bunch of carnival equipment or whatever in between, doesn't behave like-- - Yeah. - Like you expected it to. - I can open field where I can have line of-- - Line of sight, you're as opposed to going through a bunch of humans, carnival equipment. - Absolutely, you know, it's even, it's used the marathon for, for an example, the half marathon and the 4K and whatever else goes on on Saturday, that's in such a compact space that they can use a simplex talk around channel for communications with the radio system that we UH have and we bring to our UH sponsored events. But the course for the full marathon is so expansive, we actually have to go sit on a bridge with a repeater masked up in the air to be able to cover that entire span and use a completely different strategy for communications and something like that. In the space of the canfield fair, do you guys use a radio system or use a Markz or-- - So we're on Markz radios and they actually have it set up for very fortunate for this because it is such a huge fair ground, there are so many people that we actually are radioing into their true dispatch. So we actually don't do any type of patching or anything like that. - That's awesome, yeah. - So they set up two dispatchers, one for the fair and one for their normal 911 calls. - Oh, that's awesome. - And one thing I did learn through my event medicine years is nurses aren't taught how to talk on a radio. - Fair. - So that was something when we started adding nurses in at the fair is I was like, okay, here's how you push the button, here's how you talk and people don't realize nurses are never taught that. - Yeah, here's the cadence, here's the-- - Right, and if you didn't grow up with fire, family and police family, you've never heard radio chatter - How to acknowledge and respond and stuff. - No, that's very reasonable. If you're using, let's just expand that, you're obviously focused on nurses, but if you're using volunteers-- - Correct. - Oh, yeah. - You've got people doing traffic control for you or whatever the case may be, they might not be familiar with that. And marks for anybody that is our statewide trunk radio system that we have here in Ohio. - The other thing too, on top of communications and in radio communications, you might have a cellular problem. - Ah, which we do every area. - So really to the fair, did you bring in mobile repeaters? Did you test that, no matter what your vendor is, Verizon, FirstNet, AT&T, et cetera? I can tell you that our current vendor, that is one of our sponsors, works really well there. FirstNet works very well. We had some other vendors, it did not work well, even with on-site repeaters, boosters. So that can be difficult, not only to us as maybe we're trying to chart on an iPad, but it's also difficult for that person that's trying to get out and call 911 now. So if they're unable to make that call, what are they gonna do? They're probably gonna run to the closest food truck or maybe the first aid station or they send someone actually to run to the first aid station and say, hey, this person over here needs help, and you don't know how far they came. I think those things is a good education piece, not only to our viewers, but to the general public. Hey, if you're coming to this event, think about these types of things. Know where the first aid stations are. We put a lot of good signage up there, trying to direct people, but I attended a country fest down at Clay's Park, it's the same way. As soon as you put that many people into a small area, not everybody's cell phone works. Yeah, you could take a video or a picture, but they're not able to get out and call 911. So those are other things that we have to think about. Even in a situation where, I can remember this happen, when did the, they were the Indians at the time, not the guardians, when did the Cleveland Indians go to the playoffs or what? Anyway, so it was late '90s? It was late '90s, I think it was late '90s. So many people, normally great service area, right? So many people were on the system that they essentially collapsed it, right? There was just straight overload. So let's transition that to the perspective of a mass casualty incident or something. Yeah, everything's fine, everything's working now, but now if everybody in this space tried to make a phone call at the same time, I mean-- It's supposed to try to make a 911 call, right? 911 call. Sort of prioritizing all that traffic that's coming out from one cell site that's at a community fair, let's say it's, can't disagree, one, that they don't have that much volume on that network at any given time, other than the one week a year that the fair's there, right? So there's just-- 348 days a year, it's not taxed, right? And now we're at 200% of its capabilities, and now I'm receiving all these calls for service that it just, the system can handle it. Correct, so you brought up FirstNet Verizon. I mean, most of these larger cell phone companies, they'll have some sort of device they can bring out, whether it's a mobile tower, somebody's got a drone. At FirstNet's got a, somebody's got a drone, I can't remember who, you know, but they can add capacity for these temporary surges, these planned surges, right, to, you know, to aid and help in that and should be part of any of your considerations, right? Yeah, it's something you have to think about, it's gonna benefit the public, but it's also going to prevent, you know, like in our world for event medicine, it's gonna help us because how do we do all of our charting, how are we doing our patient reports, how did the majority of all of our ambulances under our medical direction do that? It's all going to be, you know, network- Some other data, yeah, so you look at it, so you have to have tests and, you know, you need to do dry runs, test things, be as prepared as you possibly can, or you're gonna have, you know, a failure in that. I don't know. You know, again, we'll, on the communications thing, we're talking about the cell service, you know, we'll look at, like, with the marathon, we don't rely on people to call 911 if a runner goes down, there's spotters all along that course, and in that particular case, that's where the amateur radio guy's from Caioga County, which is where that's run at. They volunteer, they man that, they put radio operators all along the course, and they're honestly, we spend more time getting information on the communications side of thing, in from them, and then we do our own trained providers, and/or cell phone calls, right? 'Cause they watch them go down, and they're just on the radio immediately, 'cause they position themselves to see a big swap. So, you know, depending on what your event is, you know, maybe you need, maybe you need spotters, let's say there's no chance of, you know you're in a bad cell spot, right? It's not big enough for them to want, bringing out a mobile tower, or, you know, some of these other resources, maybe that's, you have to have some sort of a system like that, where even if they're your people, but they're just staged in a position where they can radio in to whatever your command center looks like for that. - Well, we just had the big eclipse, right? - Perfect, yeah. - And then for Portage County, part of the plan was, is actually relying on amateur radio, and we pre-positioned them at hospitals, places, so in case, cell tower goes down, marks go down, I have now back up point-to-point and ham radio operators that we can communicate with. All part of the plan. - What about facilities? I think facilities is, again, gonna be relative to size of your event, right? If it's, you know, you're doing something for a couple hours, fireworks or something like that, probably don't need to set up a hard shelter of any kind, but if you're gonna, if you have, you can anticipate processing, lots of people is probably worth having some sort of fixed location, whether that's bringing in an event service with a big tent or a trailer or something like that, but when you're doing that, of course, I think taking into consideration what time of year and heating and/or cooling is. Honestly, I find that to be specifically in the summer when most of these things happen. Honestly, the cooling and the availability of ice and stuff like that becomes, it seems like it's always a challenge and some of the things I've been involved in. - Well, those are your, that's your big thing you're gonna be fighting with is the environment, right? So if it's in the summer months, you have to worry about people getting too hot and dehydrated. If you have a facility that you can, a field hospital almost set up to bring them back to, that you're gonna have your ice already and you're maybe gonna have your water cooled and ready to go. And more ideally, to have that and we have this at Canfield Fair, a building that's air conditioned. So if you can set that up ahead of time and say, "This is gonna be my field hospital," bring sick to me, we can have most of our supplies there to help manage those patients initially. And they're in an air conditioned cold environment that's gonna help. Flipside is, let's say you're doing a, more in Northeastern Ohio, we're doing a polar plunge in the middle of winter. If I could set up some tent building that I can heat. - Warm it in. - So that way, if I have people that are cold that can come in, they have some place that they can warm up. So getting those environment, fighting the environment's the big thing for these events. And the problem is we're not doing it with one patient. Once it gets hot enough or cold enough, you're not gonna have one patient that goes down and have multiple. - You're gonna have multiple, yeah. - And how do you manage all those people at once? - The, you say that and I flashed back to, I think it was 2014, maybe 2015 with the Cleveland Marathon. - Yes. - We had-- - I was there. - Every single season in the same day. - Yes. - Oh, yes. - In half? - We treated hypothermia and hyperthermia and everything in between, all in the same day. And oh, it's always that miserable. And I got carbon monoxide poisoning that day too. So turns out the heater in the comms truck had a small issue, small issue. - One thing for us at Canfield Fair, like to think about is you're gonna use your dunk tank. Well, where are you gonna get all the ice from, right? We don't have freezers just making ice, so it's finding some place to contact, to have ice that you have it when you need it. And you know, no, we may not need it this day 'cause it's gonna be, you know, 60 and rainy, but on the day that it's, you know, 80 and sunny and beautiful and everybody comes out from newborn babies to 103-year-olds that wanna make it to the fair and I've been here every year of my life, we have to take care of those people and plan for those people to have heat issues. - Yeah, you bring up a good point specifically with the summer months is standard of care for hyperthermia now is to dunk them, right? Is to dunk them, not to, you know, pack some ice packs on them and spritz them with a spray bottle and hope they get better. It's one thing if they're uncomfortable, but if they're physiologically ill from, you know, from a heat emergency, you have to have that availability of a vessel large enough to dunk somebody. And like you said, the availability of ice, like I think I said a minute ago, it seems like that's always a thing, is the availability of ice and water to some extent. And I know, I mean here in our prep for various events, we just have pallets of water, right? We just pallet, drinking water as well as just five gallon drums staged, ready to fill up dunk tanks or whatever we need. But yeah, all that needs to be, that's not something you should be ad-hocking real time. Of course, there are ad-hock methods of managing that, but that shouldn't be your plan going in if you're expecting any volume of, any volume of people. - Yeah, definitely if you're gonna be out and dealing with temperature emergencies, you need to be prepared for those. You're prepared, it's not a tarp and we'll go get some ice. It's have a vessel you can dunk somebody in, or if it's going to be, if you're cold, need to warm somebody up, have a bear hugger, talk to whatever you can to get a quick way to warm these people out of the world. I know how water's not necessarily recommended anymore, but something may be better or nothing. - True. - In some of these cases, yeah. - And for the heat emergency is like, we learned very recently in the last 10 years that the transport time from wherever that patient's at to a hospital, they're gonna get worse and worse the longer that you have to transport them. So we wanna treat them on scene, we wanna get their temperature down below 102, and then transport. It's given them under 102 is what's the most important part of those emergency services. - Yeah, that case we just had, exactly that happened. They were at 108, they dunked them, they got them down to I think 103, at just about the 30 minute mark, and the decision was made to go. And you know, maybe in hindsight, they should have left them in a little longer, but patients started getting worse. And then they probably only had a 15, 20 minute run to the hospital, but they, you know, mental status was declining yet again, as they were-- - But that's something to think about as your transport time, right? Because if you're coming to an event, for example, I've sat in traffic going into the Canfield Fair for an hour and a half, two hours, well, the ambulance can't just go. So you have to consider that also, are they safer on scene with us? Then they are sitting in the back of an ambulance with one paramedic sitting in traffic. (dramatic music) (dramatic music) (dramatic music) (dramatic music) (dramatic music) (dramatic music) [ Silence ]