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EMS coverage for mass gatherings and public events

Understand the factors that impact crowd safety and how to prepare your agency for protecting the public at a mass gathering or special event

Many factors influence crowd safety and EMS planning for a mass gathering.

This article was originally posted Aug. 28, 2015. It has been updated with new information.

EMS systems are called upon to perform a variety of functions in protecting community health. Providing standby medical coverage for large gatherings such as sporting events and fairs is a specialized task that requires significant preparation to fulfill reliably and efficiently. Unscheduled public gatherings, such as memorials and protests, cannot be pre-planned to the same extent, but you can prepare in advance. With proper planning and communication among stakeholders, EMS providers can provide effective coverage that can scale rapidly in case a mass casualty event occurs.

What is mass gathering and why is it different?

Perhaps not surprisingly, there is not one single definition as to what constitutes a mass gathering. The National Association of EMS Physicians (NAEMSP) states that a mass gathering is an “organized emergency health services provided for spectators and participants at events in which at least 1,000 persons are gathered at a specific location for a defined period of time” [1]. The World Health Organization defines a mass gathering as “an organized or unplanned event where the number of people attending is sufficient to strain the planning and response resources of the community, state or nation hosting the event” [2].

These two definitions could be combined to define a mass gathering as a large group of people who gather for a specific purpose, at a specific location, where the potential for emergency response is significant and would overwhelm the daily operating resources of the local EMS system.

More practically speaking, examples of mass gatherings include events such as:

  • Festivals and fairs
  • Sporting events at the college and professional level
  • Major political and social events
  • Air shows, auto races and music concerts
  • Religious gatherings
  • Running, biking and triathlon races
  • Memorials
  • Marches, parades, protests

In these examples, the incident population could range from hundreds to tens of thousands of people or more. This can result in a large number of people crowding into a small physical area. Panic stampedes at concerts, major religious, holidays and sporting events have occurred numerous times over the years, as well as support structures that fail under the weight of spectators [3]. Mass gatherings, like the Boston Marathon, can also be targets for terrorists, or violent attacks, like the Route 91 Harvest Festival in Las Vegas.

6 Factors that can affect crowd safety

These 6 factors can impact crowd safety and EMS response.

1. Weather

There are several factors that can uniquely affect the dynamics and subsequent EMS response to a mass gathering. Weather can have a serious impact on a crowd that is unprepared for it. Heat and humidity can result in rapid dehydration and subsequent heat exhaustion, especially for pediatric and geriatric patients. Rain, snow and cold can produce hypothermic conditions, as well as hazardous footing that can result in fall-related injuries. Keep in mind weather can impact participants, like marathon runners, and the spectators that spend hours outdoors cheering on the runners.

2. Age

Attendee age and prevalent medical conditions can raise the potential for a large number of patients. Older patients have fewer physiologic coping mechanisms and are less likely to endure long periods of standing, elevated temperatures and other environmental conditions.

3. Drugs and alcohol

The focus of the festival can bring unique confounding conditions. Readily available alcohol and recreational drugs raises the possibility of overdose, trauma and violence. While event organizers attempt to provide safe operating conditions for both spectators and participants, events such as air shows and auto races have the potential for crashes that affect the overall population [4].

4. Location

Where the event is located adds yet another complication. A fair or festival may have limited access and exit points in order to restrict entry to the public, but can also create chokepoints for incoming response resources.

On the other hand, a parade, marathon or bicycle race may stretch across an entire city, spreading onsite resources very thin and potentially making it difficult to pinpoint a precise incident location.

5. Timing

The length of the event presents its own challenges. While most gatherings might last less than a day, a multi-day or even multi-week event can present significant logistical issues for participants, from available drinking water and food supplies to sanitary and trash services. Prolonged events also create a logistical challenge for EMS leaders to provide rest and refreshment opportunities for providers, shift changes, and equipment restocking.

6. Potential for violence

The potential for intentional violence at high-profile mass gatherings have added yet another layer of complexity to incident planning. The 2013 Boston Marathon bombing demonstrated how critical surge capacity was in managing the critically injured and transporting them in appropriate order.

Memorials, political marches and protests also present a potential for violence and injury, like the Ferguson riots or the protests after the death of George Floyd.

Early planning is critical

Given the complexity of a mass-gathering event, the EMS response may be as simple as a few medical units being stationed at the site, supplementing other medical resources, or as sophisticated as a mini-EMS system, with its own station, dispatching and freestanding emergency department. Each configuration requires forethought and careful planning.

It very likely that any planned event will require some type of approval from the local or regional authorities in order to operate. Public safety providers, such as EMS, should have a set of requirements that the sponsoring agency must meet before an event is approved.

During the planning phase make sure to not overlook the importance of reimbursement for EMS-related expenses. Will participant fees and ticket sales pay for EMS providers, disposable supplies and other costs?

An incident plan is mandatory. Given the parameters described earlier, each facet must be thought out carefully, with appropriate agencies, personnel, equipment and other resources allocated. The Federal Emergency Management Agency (FEMA) has a series of templates and guidance that local agencies can use to plan and organize an EMS response [5].

Coordinate public health response

It’s critical that all stakeholder agencies are involved at one level or another during the planning and subsequent notification process. EMS, law enforcement, and fire services are responsible for providing public safety; coordination among these agencies must ensure a clear line of reporting and a comprehensive communication system.

Often medical facilities are staffed at the larger events, either through a contracted clinic or hospital medical provider, EMS, or a combination of both. Roles and responsibilities for all health care providers must be clearly defined so overlap of function is minimized and no gaps in coverage are created.

While most event-related illnesses and injuries are minor, hospitals must be made aware of the potential of a surge in patient load in case of disaster. Arrangements for offsite transport via ground ambulance and/or air medical services should detail staging areas, pickup points and access/egress locations.

Public health authorities are responsible for sanitation concerns surrounding toileting and cooking. While not obvious, reducing water and food-borne illnesses can minimize the potential for outbreaks within the event population.

Other services might include utility services, towing companies for keeping safety lanes open, and neighboring public safety agencies for mutual aid if needed.

Command and control

While small sized gatherings may require a simple command structure, medium- and large-scale events require the use of incident command system (ICS). All personnel should be well versed in standardized emergency management systems (SEMS) and be prepared to assume any role if a disaster strikes. During normal operations, SEMS can be used to maintain a cohesive line of communication among providers.

Personal preparation for personnel

Staffing a large scale event is significant. EMS providers should make sure they follow a few basic tips in order to remain alert and prepared to respond [6]:

  • Sleep well the night before and stay rested during the event.
  • Use sunblock and bug repellent if appropriate to the venue.
  • Stay hydrated by drinking water and avoiding caffeine-containing beverages.
  • Eat healthy and avoid overeating.
  • Dress in layers in order to stay warm during overnight and early morning hours, and to stay cool during the daytime.
  • Avoid injury by stretching and walking regularly during the event.

For a long duration event, staff schedules should allow for adequate rest periods and “off duty” time so that personnel can perform at their best while on duty.

With careful, thoughtful planning and resource allocation, EMS systems can be well prepared to manage mass gatherings effectively and without fanfare.

Read next: 5 lessons for special events standby services and emergency response


  1. De Lorenzo RA. Mass gathering medicine: a review. Prehosp Disaster Med 1997;12:6872
  2. World Health Organization. Communicable disease alert and response for mass gatherings: key considerations. June 2008.
  3. Mohan KM. Human stampedes during religious festivals: A comparative review of mass gathering emergencies in India. International Journal of Disaster Risk Reduction 09/2013; 5:10–18.
  4. Ballard, SB; Osorio VB. U.S. Civil Air Show Crashes, 1993 to 2013: Burden, Fatal Risk Factors, and Evaluation of a Risk Index for Aviation Crashes. Transportation Research Record 05/2015; 2471:1-9.
  5. FEMA. Operational Templates and Guidance for EMS Mass Incident Deployment. 2012. Retrieved 12 August 2015.
  6. Jaslow D. Best Practices: Mass Gathering Events. EMS World 7/2006.

Art Hsieh, MA, NRP teaches in Northern California at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. An EMS provider since 1982, Art has served as a line medic, supervisor and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook writer, author of “EMT Exam for Dummies,” has presented at conferences nationwide and continues to provide direct patient care regularly. Art is a member of the EMS1 Editorial Advisory Board. Contact Art at and connect with him on Facebook or Twitter.