Marathons, triathlons and other active participation events need to treat nearly any patient condition without straining local EMS and hospital resources
By Matt S. Friedman MD and Connor B. Fitzpatrick
Surges happen. Whether there is country concert or an electronic dance music festival, you must be prepared to provide continuous medical care. Mobile ER Trailers are the solution; a mobile emergency room that provides immediate access to critical care.
Depending on the anticipated size, number of active participants, viewing capacity, and risk for terrorism, natural disaster or extreme weather, each mass gathering requires a unique disaster plan and event-specific risk mitigation procedures.
Typically, medical care offered at these events is provided in a large tent at the finish line and several smaller tents along the racecourse. There are unique challenges and tangible limitations when providing medical care in tents without a surge capacity capability. While this system has been in place for decades and may provide quality medical care to the majority of event participants turned patients, there may be a better way.
When a needs assessment of a predetermined MCI requires additional resources, a mobile ER trailer is an option to provide high-quality, efficient, cost-effective, and advanced medical care that is comparable to treatment offered in the closest emergency room.
Most patients can be managed in the mobile trailer throughout their emergency treatment course while a few may need transport for definitive care at a tertiary care facility. Even those patients who need transport can be sufficiently stabilized in the mobile trailer given its capability to provide for aggressive and advanced medical care directly on-site. Some mobile trailers are configured to have small OR suites to offer surgical procedures ranging from appendectomies to splenectomies. The following six features methods can enhance the quality of medical care offered in the prehospital field by providing a mobile ER trailer as opposed to the current standard quo of a finish line tent or transport to a local hospital:
1. Controlled environment for emergency care
A controlled environment is a clean, comparatively sterile work environment where you have the space, maneuverability and equipment to handle the worst-case scenario. If you are anticipating patient presentations aside from contusions, lacerations and other musculoskeletal injuries, there is a medical advantage to having a controlled environment such as the mobile emergency room trailer on-site.
Typically, at active participant events, patients present with a range of benign complaints to more severe conditions such as dislocated joints or critical asthma exacerbations. Procedural sedation is utilized to reduce shoulder, elbow or hip dislocations and this procedure should be done in a more controlled setting. Likewise, patients with severe asthma exacerbations should be administered continuous nebulizers, intravenous steroids, magnesium, ketamine for difficult to treat cases, and CPAP. The regimen of medications and the space to adequately treat and assess the response to treatment is more adeptly delivered in a mobile ER trailer.
Mass gathering medicine literature reveals that weather patterns and specifically heat index is directly correlated to patient presentation rates. A mobile trailer has better climate control than most tents and offers a respite from extreme weather. Patients are protected from the environmental elements that may have initially contributed to their condition requiring emergent evaluation. Whether it’s heat in frigid weather, air-conditioning in humid weather, or suitable shelter during a lightning storm, there is a clear benefit to having a fixed structure.
Similarly, some events are held during the summer months with predictably bad weather such as an attendant high heat index or frequent lightning storms. While some tents may have HVAC units attached to one end, a mobile trailer offers ventilation ports positioned throughout the patient treatment area and therefore more effective climate control. Additionally, having a mobile ER trailer on-site obviates the obligatory challenge of evacuating tents during a lightning storm.
2. Patient privacy during care
Inside a mobile trailer, there is room to treat patients in a private and humane environment. Patient assessment and treatment can be provided out of view of other participants and spectators in cordoned off private areas. Obtaining rectal temperatures to determine who is mildly hyperthermic from those patients with end-organ toxicity resulting from severe hyperthermia is more easily performed. An EMS staff that treats patients humanely in some of their worst hours is indicative of those with mass gathering professional experience. There should be no reason to completely expose a patient in full view of other patients and participants just because they happen to be in extremis at a mass gathering. While patient exposure is paramount in many conditions, it should be done in a professional, dignified manner that the medical team is proud of when clinically debriefing the resuscitation at a later point.
3. Capability to treat severe illness or injury
There are improved patient outcomes with lower morbidity and mortality rates when advanced medical care is provided on-site to treat the critically ill. Whether it’s rapid cooling in severe hyperthermia to prevent multi-organ failure, early intravenous steroids and ventilatory support to reduce work of breath and decrease hypercarbia in severe asthma exacerbations, adequate sedation to treat excited delirium secondary to psychostimulant drug-induced toxicity (PDIT), or hypertonic (3%) saline administered through central intravenous access to reverse hyponatremic seizures, patients have fewer sequelae with aggressive treatment early on. Most importantly, cardiac dysrhythmias secondary to acute coronary syndrome or severe electrolyte derangements can be terminated quickly and effectively preventing the patient from sustaining cardiac arrest.
A mobile ER trailer allows multiple providers to gain access to a patient in extremis obtaining intravenous access in the bilateral upper extremities while another provider places the patient on a cardiac monitor and obtains vital signs including core (rectal) temperature while yet another provider is at the head of the bed managing the airway and comforting the patient if responsive. The resuscitation bay is typically superior to the space afforded in a tent secondary to enhanced lighting, climate control, maneuverability, access to equipment, and potential for more capabilities such as point of care ultrasound, X-ray machines or even computed tomography.
4. Supplies and point of care labs
Mobile trailers typically have well organized cache cabinets offering ready access to stock supplies. Additionally, they should have proper CLIA licensing credentials in order to run point-of-care serum and urine analyses. Utilizing the serum pH and the partial pressure of carbon dioxide is incredibly helpful to determine the criticality of the patient and responsiveness to therapy. They arrive fully equipped without the traditional limitations of medical distribution companies whose inventory can be precarious in times of national shortages.
Mobile ER trailers should be completely self-sustaining for 72 hours, more than enough for any active participation event, and equipped to treat a range of medical conditions. They can be operational within hours of arriving on-site, and can carry and accommodate expandable tents to significantly enhance their surge capacity. If a hurricane, flood or wildfire damages traditional infrastructure reducing their patient capacity, the mobile trailer can accommodate the surge capacity which typically begins immediately and may last for weeks.
5. Reduce burden on local emergency services
One particularly beneficial feature of a mobile ER trailer providing care at a mass gathering is avoiding the disruption of healthcare services to the hosting community. There have been many notable public outcries reported in the media about local hospitals that were ill equipped to handle the excessive number of patients transported from a mass gathering. The hosting community should be able to rely on a timely response from their usual 911 resources without fearing EMS personnel and ambulances will be diverted to a mass gathering. If it becomes necessary to activate emergency services to respond to a mass gathering, response times are typically delayed due to road closures, traffic detours, and excess vehicle volume.
A much safer alternative is to have sufficient resources on-site to treat patients. The self-reliant staff in mobile trailers is able to treat most patients on-site and dramatically reduce the number of transports. Since the mobile trailer is treating and dispositioning most, if not all patients, local hospitals will not receive surplus patients disturbing the hosting community from receiving the medical care they deserve. Additionally, many local hospitals typically upstaff during mass gatherings dramatically increasing the cost to the healthcare system.
6. Dedicated space for medical team
Finally, mobile trailers offer the medical staff a place to congregate and escape the environmental elements as well as the opportunity to recuperate. Whether the staff needs to warm up, cool down, hydrate, or change out of soaking wet, muddy or soiled uniforms, they are afforded the professionalism and the privacy that is provided by the mobile trailer.
About the authors
Matt S. Friedman, MD, FACEP, DABEMS, is the Associate Medical Director of Prehospital Care and Director of the EMS Clerkship at Maimonides Medical Center, Brooklyn, N.Y. Dr. Friedman is the national medical director of CrowdRx, Inc. and has served as the Lead House Physician for Yankee Stadium, Madison Square Garden and the US Open since 2013. With CrowdRx, Dr. Friedman is the annual medical director for Burning Man, Moonrise Music Festival and many other annual mass gatherings.
Connor B. Fitzpatrick, AEMT, is the Executive Director at CrowdRx (A Global Medical Response Solution), coupling his background in emergency medical services with his extensive experience in healthcare operations to build strategic partnerships with venues, sponsors, and clients. He is also certified by the Department of Homeland Security as an Incident Response to Terrorist Bombings Instructor, by CONTOMS as a Tactical EMT, and as a Connecticut POSTC Police Instructor.
The CrowdRx mobile ER trailer is 24’ by 53’ and capable of treating conditions from minor musculoskeletal complaints to life-threatening anaphylaxis to hyperthermia or hyponatremic intractable seizures.
