SIDELINE AND EVENT MANAGEMENT
Unexpected Disasters at Organized Sporting Events: Considerations in Preparation and Response Thad Woodward, MD1; Ferheen Shamim, MD2; Michael Hinson, DO2; and Evan Bass, MD2,3
Abstract Preparing for the unexpected or unusual occurrence is always a challenge. When you add large collections of athletes and spectators, that challenge is certainly magnified, and proper planning and preparation are even more critical in reducing the damage done. The aim of this article is to stimulate thought toward preparing the medical director and staff in being ready to respond to the unexpected disaster at a sporting event.
Introduction Dwight D. Eisenhower is credited with saying ‘‘Plans are nothing; planning is everything.’’ It is nearly impossible to fully prepare for all unexpected events that can occur in life, but having some key elements and general response protocols can certainly improve outcomes should an unexpected event occur. While much is written about preparing and responding to disasters for the common civilian in his or her home as well as about preparation for mass participation events, there is not much literature available discussing how a medical team at a sporting event should prepare for general unexpected events. With this article, the authors attempt to provide considerations for the medical director and team in preparation and response to potential disasters at a sporting event. Due to the broad and variable nature of the topic, the information provided must be used as only a starting point in developing a customized medical action plan for any given situation. It also should be made clear that there are no mandatory requirements for treatment levels when you are developing an operational plan. It
1 Kaiser Permanente, Woodland Hills, CA; 2Team To Win Primary Care Sports Medicine Fellowship, Harbor-University of California Los Angeles, Harbor City, CA; and 3Kaiser Permanente, South Bay, CA.
Address for correspondence: Thad Woodward, MD, Kaiser Permanente, 5601 DeSoto Avenue, Woodland Hills, CA 91365; E-mail: [email protected]. 1537-890X/1403/171Y175 Current Sports Medicine Reports Copyright * 2015 by the American College of Sports Medicine www.acsm-csmr.org
is the decision of the medical director based upon his or her training level and experience and that of the staff and volunteers as well as the resources available for the event.
General Disaster Preparedness While each event deserves its own analysis and resultant plan, there are some common key features that must be considered in preparation for any unexpected crisis. Situational awareness and communication are two of the most vital issues when dealing with mass participation events. Situational awareness is crucial in effectively treating sudden large volumes of patients when limitations of resources, transportation, and assistance exist. You must clearly know the medical training and numbers of the volunteers at your disposal. Even if you have too many medical volunteers for the event medical team, consider asking extra volunteers to come as spectators that can provide additional on-site help should a crisis develop. Consider surveying the event participants for emergency, crisis, and/or medical training, and apprise them of your plan of action in the event of an unexpected disaster. This can be done by coordinating with event management and incorporating focused questions in applications and other event communications. Another way would be to request information voluntarily from participants on event Web site or announcements by directing them to a link or phone number. You also must have thorough knowledge of local disaster and emergency services. Notify all local paramedic and ambulance services available regarding the event. Have a thorough list of trauma centers, emergency rooms, and urgent care centers in addition to all local hospitals. Contact local schools and churches that possibly could serve as crisis triage centers and shelter for victims. In addition to availability of personnel, situational awareness also must deal with access. Sporting events often create a change in normal patterns of access due to road closures, crowds, and traffic. Have advanced meetings with local police and fire leaders to discuss access, maintenance, and Current Sports Medicine Reports
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
171
evacuation routes. Always have at least two well-separated access points in case one is affected by the disaster itself. In addition to situational awareness, solid communication methods are vital to effective disaster response. Lack of information and communication can be one of the most crippling aftereffects of a natural disaster. Not knowing where to go and what areas are safe can lead to further risk of casualties and injuries. Mobile phone service may become unreliable during a disaster, so always consider radio communication with key members of your team. Consider having a plan for your medical team members to report immediately to a designed site (usually the main medical tent) in the event of a disaster. Have a reliable method to make announcements (PA system, megaphone backup) available to deliver information and instruction to large groups of people. If possible, you should always strive to have a representative from the fire department posted in your medical tent command area. This facilitates a more efficient and coordinated response to the usual expected events but, in the case of a disaster, also will allow you to integrate into the overall response under the fire department and the incident command system if being used in your area. If this is not an option, a radio capable of direct communication with the fire department should be in the medical command post. Supplies in Preparation for Unexpected Disasters In addition to stocking ample medical supplies for abrasions, cuts, and orthopedic injuries, medical directors may find that having a ‘‘disaster bag’’ ready with different sets of supplies may be useful. The authors have composed this list of items to assemble in a ‘‘disaster bag’’ or cache that can be of use in providing emergent medical care in the setting of a disaster. Keep in mind that these are suggested items and are dependent upon available resources and support.
to review triage systems, but most systems use the colored system, as follows: ) Red: critical ) Yellow: urgent but not critical ) Green: minor ) Black: deceased
& Material supplies ) Several long coils of rope or paracord or ‘‘caution tape’’ rolls that can serve to cordon of areas and can be used as makeshift tourniquets or in improvised shelter ) Tarpaulins for shading/shelter from elements and ground cover ) Duct tape for both improvised splinting but also for setting up tarpaulins/shelter ) Zip ties for cable/cord management and shelter improvisation ) A battery-operated radio with weather channels ) Consider a generator for backup power for lighting, fans, and communications ) A battery-operated PA system, megaphone, or bullhorn ) LED headlamps: inexpensive and can provide good lighting during power failures ) Propane portable heaters ) Large propane fryer (sold at most hardware stores) with instant soup mix: can be used for coldtemperature events but also comfort food in case of disaster with extended time to restoration of services
& Advanced
medical supplies (purely optional and based upon skills of the medical team involved and review of potential risks for the event)
& Medical supplies ) Tourniquets or material that can be fashioned into a tourniquet ) Extra stores of gauze, 4 4s, abdominal pads, military dressing, medical tape, and other supplies that could be used for pressure dressings and bandaging ) Topical hemostatic agents ) Extra stores of saline for irrigation of wounds. Expired IV bags or bottles are fine for this purpose. Lacking that, containers that could be used to bring tap water should be on hand. ) Vaseline with nonadherent dressings that could be used for penetrating chest cavity injuries ) Several sets of trauma shears for removal of clothing or cutting rope ) Cardboard splinting material ) Mylar (‘‘space’’) warming blankets ) Masks to prevent/isolate ill athletes or spectators if sheltering in closed quarters ) Hand sanitizer
& A tagging system for triaged victims, either a commercially available system or clearly visible colored tape from the local hardware store, to identify disposition of triaged victims. It is beyond the scope of this article
172
Volume 14 & Number 3 & May/June 2015
) Airway management ) Nasopharyngeal tubes ) Blind intubation equipment (various types) ) Cricothyrotomy kit ) Bag valve mask ) Chest tubes ) Needle thoracostomy kit ) Amputation kit ) Appropriate medications and skin preparation supplies to perform the mentioned procedures Initial Response to a Disaster Following an unexpected disaster, perform the following:
& Immediately collect your medical team to prepare a coordinated response.
& Review safety issues for staff and volunteers. Initiate & &
any security protocols that were created with appropriate agencies involved with the response. Identify ongoing threats and remove victims and potential victims from areas of concern. Review predesignated treatment locations identified as areas where victims could be safely triaged, treated, Unexpected Disasters at Organized Sporting Events
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
& &
monitored, and protected until transfer to an appropriate level of care can be arranged and decide which to utilize. Help calm and control panic. Advise fire department (or other agency you may be working with at the event) of your status, needs, and capabilities when able.
Special Considerations for Specific Threats Thunderstorms and Lightning (Electrical Storm) If an electrical storm is anticipated, it is certainly safest to postpone the event. In the event of an unexpected electrical storm, the first response should be to assist participants to shelter. Have a battery-operated NOAA weather radio for updates. If you hear thunder, immediately start your shelter plan. If the event is in a covered venue, have an effective plan to keep athletes and spectators in the venue to allow the storm outside to pass. You should wait at least 30 min after the last clap of thunder before declaring the area safe (4,15). Effective communication methods with crowds of athletes and spectators are mandatory (4,15). At an unsheltered event, the medical team should be aware of available shelter nearby. A fully enclosed building with plumbing and electrical wiring is much safer than a shed or open canopy. Being in a hard-top vehicle with the windows closed also is safer. Consider using buses in remote areas. Once inside a shelter, occupants should keep away from electrical equipment and corded phones and avoid use of plumbing. If shelter is not available, then people caught in an electrical storm should be guided to the best situation possible; a lower area (valley) is preferable to a higher area, but beware of flash floods. Avoid being near single tall trees or poles. Crouch low to the ground, among large groups of trees if available, and spread out by 50 ft or more to reduce the event of multiple causalities from a single strike (4,15). Electrical injury should promptly be escalated to a tertiary care center. Lightning injuries affect 800 to 1,000 persons per year. In lightning injury, cardiac arrest is the main cause of death. Burns tend to be superficial, and injuries often are what one would expect of short-circuiting or overloading the body’s electrical systems (tinnitus, blindness, confusion, amnesia, cardiac arrhythmias, and vascular instability). Intestinal burns and necrosis also may occur and may be indications for emergent exploratory laparotomy (6,9,17). Earthquakes The most recognized sporting event affected by an earthquake was game 3 of the 1989 World Series between the Oakland Athletics and San Francisco Giants. The Loma Prieta earthquake struck during pregame warm-ups at 5:04 p.m., only minutes before the first pitch, and became the first major earthquake ever broadcasted on live television. Earthquakes can occur suddenly without warning at any time of the day or night. According to Federal Emergency Management Agency (FEMA), all states within the United States are at risk for earthquakes. Because of these unexpected occurrences, it is of utmost importance to be prepared before an earthquake occurs. Never assume everyone knows how to stay safe during an earthquake even if they live in an area prone to earthquakes. According to the www.acsm-csmr.org
California Earthquake Preparedness Survey conducted by the University of California Los Angeles (UCLA) School of Public Health, only around 60% of all Californians have learned how to be safe during an earthquake. Even a few seconds of warning can provide valuable time to enable protective actions that can save lives. Preparation for earthquakes at large scale sporting events involves the following multiple steps: (1,16).
& Make & & & & & & & &
sure large items are secure and properly braced. Hang heavy items away from spectator staging and athlete competition. Learn how to and who to contact to shut off gas. Expect aftershocks. Be aware that loss of power can often be associated with earthquakes. Loosely hanging or unstable objects can fall or collapse. Water pipe breakages and gas leaks may occur. Be aware of who to contact so that the water main may be turned off. Exposure to pathogens from sewer system breaks can occur, so have plans in place to mitigate this risk. Exposure to energized electrical wiring is a significant risk especially in combination with water main leaks.
Tornadoes Tornadoes are most frequently reported east of the Rocky Mountains during spring and summer months. There are warning systems available in most areas, but tornados can strike very quickly with little or no warning. According to FEMA, tornadoes travel across land at an average speed of 30 mph but may vary from stationary to 70 mph. Tornadoes are frequently drawn from thunderstorms, and thus, standard storm precautions should always be taken and the event should be postponed if a significant storm is developing. A tornado watch is announced when conditions are favorable for the development of a thunderstorm or tornado in the upcoming hours, but it is not imminent. A tornado warning is issued when a severe thunderstorm or tornado is occurring and sighted or imminent based on Doppler radar information. Event organizers that provide coverage in atrisk areas must be familiar with these terms and their implications. Locating the nearest public tornado shelter that can accommodate your event participants and an organized transportation plan to the shelter is strongly recommended. Public schools may be a good place to start when searching for tornado shelters; however, not all schools have shelters (3,10,11). Local public service agencies also can be a good resource for planning your response. Race organizers should consider cancelling events in the setting of a tornado watch that is felt to have a higher likelihood of producing funnel clouds, especially in locations that do not have immediate access to shelter. If a tornado warning is issued prior to the start of an event, the event should be cancelled and public announcements should be made if possible. If the event has already begun, Current Sports Medicine Reports
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participants should immediately seek shelter in the prior designated tornado shelter. If your medical team becomes involved in rescue attempts in the aftermath of a tornado, be sure that they are aware that a significant portion of injuries occur during these activities. They should not respond unless they have appropriate training in this activity and have the appropriate gear. Those that do not meet the criteria can man the medical tent to care for the victims that are found. It is always preferable to have public service agencies trained and equipped for rescue to perform those rescues and the medical team to provide care for those not needing urgent transport. According to FEMA, a study of injuries after a tornado in Marion, Illinois showed that ‘‘50% of the tornado-related injuries were experienced during rescue attempts, cleanup and other post-tornado activities. Nearly a third of injuries resulted from stepping on nails. Because tornadoes often damage power lines, gas lines, or electrical systems, there is a risk of fire, electrocution, or explosion’’ (3,11). Heavy Rains/Flash Floods Floods can occur through several different situations. Prolonged heavy or steady rains for several days or even hours can saturate the ground, causing slowly rising groundwater. Flash flooding can occur suddenly, given rapidly rising water along streams and low-lying areas. Sudden large storms that follow periods of drought can overwhelm storm drains due to debris. According to the FEMA flood preparation and safety guidelines, over the past 5 years, all 50 states in the United States have experienced flooding (2,12,13). Water mains and system pipes may break and create surprising and extensive flooding, like what occurred in UCLA in 2014, affecting multiple campus events and sporting venues including the newly remodeled Pauley Pavilion. Avoid placing your medical tent and equipment in areas when water pooling can occur, and be wary of storm drains nearby. Tent placement relative to storm drainage systems have actually created serious flash flooding within the main medical tent (author’s unfortunate experience). In this case, the site selected for the medical tent when the site plans were made placed the tent in the outflow area of several 6-inch pipes that drained a large parking lot. When there was sudden significant rainfall in excess of that expected, the drains filled the medical tent within minutes reaching a height of 1 to 2 ft, affecting medical operations and athlete care. At nonurban events, know your surrounding topography. Flash floods can be caused in hilly terrains by distant rains channeled into gullies and ravines, which in turn can cause a small, quiet stream to become a powerful and rampaging torrent. Course routes need to be reviewed for such risk and rerouted if necessary. Store important information in watertight containers. Make sure wiring and electrical components are at least 12 inches above potential flood elevations and higher if practical. Be ready to shut off breakers or generators if rising waters threaten electrical systems within your tent (2,12,13). Snow and Extreme Cold The authors recommend that consideration be given to postponing a sporting event if a severe snowstorm develops or is predicted with confidence or when wind-chill temperatures 174
Volume 14 & Number 3 & May/June 2015
are low due to considerable risk for cold-related injuries. The American College of Sports Medicine recommends that coaches, athletes, and medical personnel know the risk factors, signs, and symptoms for hypothermia, frostbite, and nonfreezing cold injuries. The wind-chill temperature index should be used to estimate the relative risk of frostbite and with heightened surveillance of athletes and spectators in these environments. A protected warming area needs to be provided. Knowledge of local shelters or use of mobile shelters (or buses) should be considered and arranged. Individuals with asthma and cardiovascular disease can exercise in cold environments but should be monitored closely. Hypothermia is characterized as a core temperature below 35-C (95-F), which represents an approximately 2-C (35.6-F) fall from normal body temperature (5,7,8,14). Unnatural Disasters Sadly, acts of terrorism have escalated around the world, with sporting competitions being a target of some of these heinous crimes against society due to their high visibility. Rioting in ‘‘celebration’’ of championships and fighting during events, both often fueled by the effects of alcohol, have unfortunately seemed to become ‘‘the norm’’ in some locations, given their frequency of occurrence these days. Being nearly impossible to predict with any certainty, the medical team must be prepared to respond and assist as it would with any disaster. Events where alcohol is served and matches between political or ‘‘arch’’ historical rivals should prompt concern. Consider contacting the local Joint Terrorism Information Center or the local police department’s Terrorism Liaison Officer for perhaps useful information regarding terrorism threat when dealing with a larger or well-known event with high participation rate. Certainly, preevent discussions with local police and fire authorities should include the topics of terrorism and riot. As with preparation for other disasters, medical directors should consider the following with regard to acts of terrorism or violence and riots:
& Only
& & &
&
allow participants from the event or medical staff inside your medical treatment areas. All athletes entering the tent should be checked in and tracked from time of arrival to time of discharge. Consider a stamp or sticker on the race bib once the athlete has been processed so that the medical team can easily identify someone that has not been processed. Have easily recognizable identification badges and clothing for the medical team. Have controlled access to your tents to keep anyone that does not have a reason to be there out of the medical tent. Maintain restricted access to the areas around your medical treatment areas and the supporting equipment such as supply trailers, generators, etc. Consider fencing for access control with a minimum of 20 ft of buffer around the medical tent and equipment. Train your team to be aware of packages, backpacks, or other items that are left unattended, and have a plan to respond to such a situation (in conjunction Unexpected Disasters at Organized Sporting Events
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
& &
with your public safety representatives involved with the event). The authors strongly urge the consideration of having physicians with advanced procedural skills on staff during high-profile events with the needed equipment to perform life-saving treatment. Have backup supplies as described at the beginning of this article available at the event, keeping in mind the treatments that can save lives in a mass casualty incident. ) Control hemorrhage (tourniquet or pressure) ) Acute coronary event (automated external defibrillator) ) Airway management ) Penetrating chest injuries (occlusive dressing for tension pneumothorax)
The following Web sites may serve as good resources when preparing for unnatural disasters:
& & &
Terrorism FEMA brochure: http://www.fema.gov/ media-library-data/20130726-1549-20490-0802/ terrorism.pdf American Red Cross Terrorism Preparedness (with sections About, Prepare, Respond During, and Recover After). January 1, 2015: http://www.redcross.org/ prepare/disaster/terrorism The Consequences of Fire: from ‘‘A Reporter’s Guide to fire and the NFPA.’’ (Copyright National Fire Protection Association 2014). Web site: http:// www.nfpa.org/press-room/reporters-guide-to-fire-andnfpa/consequences-of-fire
CONCLUSIONS While it is impossible to prepare for everything that can occur, the authors hope that the information provided can function as a guide and stimulate thought for medical directors at sporting events on how to be better prepared to take initial action should the unexpected disaster occur. Working closely with public safety agencies both in planning and implementation of the medical plan can lead to a more coordinated and efficient response and potentially reduce the often ill effects of just such an occurrence.
www.acsm-csmr.org
The authors declare no conflicts of interest and do not have any financial disclosures.
References 1. American Red Cross. Earthquake preparedness [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/earthquake. 2. American Red Cross. Flood safety [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/flood. 3. American Red Cross. Tornado safety [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/tornado. 4. American Red Cross. Thunderstorm safety [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/thunderstorm. 5. American Red Cross. Winter storm preparedness [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/winter-storm. 6. Armstrong LE, Epstein Y, Greenleaf JE, et al. Intestinal injury associated with low-voltage electrocution. J. Trauma. 1981; 21:246Y50. 7. Armstrong LE, Epstein Y, Greenleaf JE, et al. American College of Sports Medicine position stand: heat and cold illnesses during distance running. Med. Sci. Sports Exerc. 1996; 28:iYx. 8. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine Position Stand: prevention of cold injuries during exercise. Med. Sci. Sports Exerc. 2006; 38:2012Y209. 9. Cooper MA. Emergent care of lightning and electrical injuries. Semin. Neurol. 1995; 15:268Y78. 10. Edwards R. The online tornado FAQ: frequently asked questions about tornadoes [Internet]. [cited 2015 Jan 1]. Available from: http://www.spc.noaa.gov/ faq/tornado/. 11. Federal Emergency Management Agency. Tornadoes [Internet]. [cited 2014 Nov 15]. Available from: http://www.ready.gov/tornadoes. 12. Federal Emergency Management Agency. Floods [Internet]. [cited 2014 Nov 15]. Available from: http://www.ready.gov/floodshttp://www.ready.gov/floods. 13. Federal Emergency Management Agency. The risk is real: flood preparation and safety [Internet]. FEMA F-684, catalog number 09107Y2 (06/14). [cited 2015 Jan 1]. Available from: http://www.regionalinfo-alert.org/wp-content/ uploads/2014/09/FloodPreparationSafetyBrochure_F684_062014.pdf. 14. Federal Emergency Management Agency. Winter storms and extreme cold [Internet]. Available from: http://m.fema.gov/winter-storms-extreme-cold. Accessed on January 1, 2015. 15. Federal Emergency Management Agency. Thunderstorms and lightning [Internet] Available from: http://www.ready.gov/thunderstorms-lightning. Accessed on January 1, 2015. 16. Kano M, Wood M, Kelley M, Bourque L. California Earthquake Preparedness Survey Report: Findings and Recommendations for Strengthening Household Resiliency to Earthquakes. Final Report to the Alfred E. Alquist Seismic Safety Commission and the California Emergency Management Agency. 2009. Los Angeles (CA): University of California at Los Angeles. Available from: www.community.fema.gov/connect.ti/AmericasPrepareathon/ view?objectId=3229616. 17. Xenopoulos N, Movahed A, Hudson P, Reeves WC. Myocardial injury in electrocution. Am. Heart J. 1991; 122:1481Y4.
Current Sports Medicine Reports
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Unexpected Disasters at Organized Sporting Events: Considerations in Preparation and Response Thad Woodward, MD1; Ferheen Shamim, MD2; Michael Hinson, DO2; and Evan Bass, MD2,3
Abstract Preparing for the unexpected or unusual occurrence is always a challenge. When you add large collections of athletes and spectators, that challenge is certainly magnified, and proper planning and preparation are even more critical in reducing the damage done. The aim of this article is to stimulate thought toward preparing the medical director and staff in being ready to respond to the unexpected disaster at a sporting event.
Introduction Dwight D. Eisenhower is credited with saying ‘‘Plans are nothing; planning is everything.’’ It is nearly impossible to fully prepare for all unexpected events that can occur in life, but having some key elements and general response protocols can certainly improve outcomes should an unexpected event occur. While much is written about preparing and responding to disasters for the common civilian in his or her home as well as about preparation for mass participation events, there is not much literature available discussing how a medical team at a sporting event should prepare for general unexpected events. With this article, the authors attempt to provide considerations for the medical director and team in preparation and response to potential disasters at a sporting event. Due to the broad and variable nature of the topic, the information provided must be used as only a starting point in developing a customized medical action plan for any given situation. It also should be made clear that there are no mandatory requirements for treatment levels when you are developing an operational plan. It
1 Kaiser Permanente, Woodland Hills, CA; 2Team To Win Primary Care Sports Medicine Fellowship, Harbor-University of California Los Angeles, Harbor City, CA; and 3Kaiser Permanente, South Bay, CA.
Address for correspondence: Thad Woodward, MD, Kaiser Permanente, 5601 DeSoto Avenue, Woodland Hills, CA 91365; E-mail: [email protected]. 1537-890X/1403/171Y175 Current Sports Medicine Reports Copyright * 2015 by the American College of Sports Medicine www.acsm-csmr.org
is the decision of the medical director based upon his or her training level and experience and that of the staff and volunteers as well as the resources available for the event.
General Disaster Preparedness While each event deserves its own analysis and resultant plan, there are some common key features that must be considered in preparation for any unexpected crisis. Situational awareness and communication are two of the most vital issues when dealing with mass participation events. Situational awareness is crucial in effectively treating sudden large volumes of patients when limitations of resources, transportation, and assistance exist. You must clearly know the medical training and numbers of the volunteers at your disposal. Even if you have too many medical volunteers for the event medical team, consider asking extra volunteers to come as spectators that can provide additional on-site help should a crisis develop. Consider surveying the event participants for emergency, crisis, and/or medical training, and apprise them of your plan of action in the event of an unexpected disaster. This can be done by coordinating with event management and incorporating focused questions in applications and other event communications. Another way would be to request information voluntarily from participants on event Web site or announcements by directing them to a link or phone number. You also must have thorough knowledge of local disaster and emergency services. Notify all local paramedic and ambulance services available regarding the event. Have a thorough list of trauma centers, emergency rooms, and urgent care centers in addition to all local hospitals. Contact local schools and churches that possibly could serve as crisis triage centers and shelter for victims. In addition to availability of personnel, situational awareness also must deal with access. Sporting events often create a change in normal patterns of access due to road closures, crowds, and traffic. Have advanced meetings with local police and fire leaders to discuss access, maintenance, and Current Sports Medicine Reports
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
171
evacuation routes. Always have at least two well-separated access points in case one is affected by the disaster itself. In addition to situational awareness, solid communication methods are vital to effective disaster response. Lack of information and communication can be one of the most crippling aftereffects of a natural disaster. Not knowing where to go and what areas are safe can lead to further risk of casualties and injuries. Mobile phone service may become unreliable during a disaster, so always consider radio communication with key members of your team. Consider having a plan for your medical team members to report immediately to a designed site (usually the main medical tent) in the event of a disaster. Have a reliable method to make announcements (PA system, megaphone backup) available to deliver information and instruction to large groups of people. If possible, you should always strive to have a representative from the fire department posted in your medical tent command area. This facilitates a more efficient and coordinated response to the usual expected events but, in the case of a disaster, also will allow you to integrate into the overall response under the fire department and the incident command system if being used in your area. If this is not an option, a radio capable of direct communication with the fire department should be in the medical command post. Supplies in Preparation for Unexpected Disasters In addition to stocking ample medical supplies for abrasions, cuts, and orthopedic injuries, medical directors may find that having a ‘‘disaster bag’’ ready with different sets of supplies may be useful. The authors have composed this list of items to assemble in a ‘‘disaster bag’’ or cache that can be of use in providing emergent medical care in the setting of a disaster. Keep in mind that these are suggested items and are dependent upon available resources and support.
to review triage systems, but most systems use the colored system, as follows: ) Red: critical ) Yellow: urgent but not critical ) Green: minor ) Black: deceased
& Material supplies ) Several long coils of rope or paracord or ‘‘caution tape’’ rolls that can serve to cordon of areas and can be used as makeshift tourniquets or in improvised shelter ) Tarpaulins for shading/shelter from elements and ground cover ) Duct tape for both improvised splinting but also for setting up tarpaulins/shelter ) Zip ties for cable/cord management and shelter improvisation ) A battery-operated radio with weather channels ) Consider a generator for backup power for lighting, fans, and communications ) A battery-operated PA system, megaphone, or bullhorn ) LED headlamps: inexpensive and can provide good lighting during power failures ) Propane portable heaters ) Large propane fryer (sold at most hardware stores) with instant soup mix: can be used for coldtemperature events but also comfort food in case of disaster with extended time to restoration of services
& Advanced
medical supplies (purely optional and based upon skills of the medical team involved and review of potential risks for the event)
& Medical supplies ) Tourniquets or material that can be fashioned into a tourniquet ) Extra stores of gauze, 4 4s, abdominal pads, military dressing, medical tape, and other supplies that could be used for pressure dressings and bandaging ) Topical hemostatic agents ) Extra stores of saline for irrigation of wounds. Expired IV bags or bottles are fine for this purpose. Lacking that, containers that could be used to bring tap water should be on hand. ) Vaseline with nonadherent dressings that could be used for penetrating chest cavity injuries ) Several sets of trauma shears for removal of clothing or cutting rope ) Cardboard splinting material ) Mylar (‘‘space’’) warming blankets ) Masks to prevent/isolate ill athletes or spectators if sheltering in closed quarters ) Hand sanitizer
& A tagging system for triaged victims, either a commercially available system or clearly visible colored tape from the local hardware store, to identify disposition of triaged victims. It is beyond the scope of this article
172
Volume 14 & Number 3 & May/June 2015
) Airway management ) Nasopharyngeal tubes ) Blind intubation equipment (various types) ) Cricothyrotomy kit ) Bag valve mask ) Chest tubes ) Needle thoracostomy kit ) Amputation kit ) Appropriate medications and skin preparation supplies to perform the mentioned procedures Initial Response to a Disaster Following an unexpected disaster, perform the following:
& Immediately collect your medical team to prepare a coordinated response.
& Review safety issues for staff and volunteers. Initiate & &
any security protocols that were created with appropriate agencies involved with the response. Identify ongoing threats and remove victims and potential victims from areas of concern. Review predesignated treatment locations identified as areas where victims could be safely triaged, treated, Unexpected Disasters at Organized Sporting Events
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
& &
monitored, and protected until transfer to an appropriate level of care can be arranged and decide which to utilize. Help calm and control panic. Advise fire department (or other agency you may be working with at the event) of your status, needs, and capabilities when able.
Special Considerations for Specific Threats Thunderstorms and Lightning (Electrical Storm) If an electrical storm is anticipated, it is certainly safest to postpone the event. In the event of an unexpected electrical storm, the first response should be to assist participants to shelter. Have a battery-operated NOAA weather radio for updates. If you hear thunder, immediately start your shelter plan. If the event is in a covered venue, have an effective plan to keep athletes and spectators in the venue to allow the storm outside to pass. You should wait at least 30 min after the last clap of thunder before declaring the area safe (4,15). Effective communication methods with crowds of athletes and spectators are mandatory (4,15). At an unsheltered event, the medical team should be aware of available shelter nearby. A fully enclosed building with plumbing and electrical wiring is much safer than a shed or open canopy. Being in a hard-top vehicle with the windows closed also is safer. Consider using buses in remote areas. Once inside a shelter, occupants should keep away from electrical equipment and corded phones and avoid use of plumbing. If shelter is not available, then people caught in an electrical storm should be guided to the best situation possible; a lower area (valley) is preferable to a higher area, but beware of flash floods. Avoid being near single tall trees or poles. Crouch low to the ground, among large groups of trees if available, and spread out by 50 ft or more to reduce the event of multiple causalities from a single strike (4,15). Electrical injury should promptly be escalated to a tertiary care center. Lightning injuries affect 800 to 1,000 persons per year. In lightning injury, cardiac arrest is the main cause of death. Burns tend to be superficial, and injuries often are what one would expect of short-circuiting or overloading the body’s electrical systems (tinnitus, blindness, confusion, amnesia, cardiac arrhythmias, and vascular instability). Intestinal burns and necrosis also may occur and may be indications for emergent exploratory laparotomy (6,9,17). Earthquakes The most recognized sporting event affected by an earthquake was game 3 of the 1989 World Series between the Oakland Athletics and San Francisco Giants. The Loma Prieta earthquake struck during pregame warm-ups at 5:04 p.m., only minutes before the first pitch, and became the first major earthquake ever broadcasted on live television. Earthquakes can occur suddenly without warning at any time of the day or night. According to Federal Emergency Management Agency (FEMA), all states within the United States are at risk for earthquakes. Because of these unexpected occurrences, it is of utmost importance to be prepared before an earthquake occurs. Never assume everyone knows how to stay safe during an earthquake even if they live in an area prone to earthquakes. According to the www.acsm-csmr.org
California Earthquake Preparedness Survey conducted by the University of California Los Angeles (UCLA) School of Public Health, only around 60% of all Californians have learned how to be safe during an earthquake. Even a few seconds of warning can provide valuable time to enable protective actions that can save lives. Preparation for earthquakes at large scale sporting events involves the following multiple steps: (1,16).
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sure large items are secure and properly braced. Hang heavy items away from spectator staging and athlete competition. Learn how to and who to contact to shut off gas. Expect aftershocks. Be aware that loss of power can often be associated with earthquakes. Loosely hanging or unstable objects can fall or collapse. Water pipe breakages and gas leaks may occur. Be aware of who to contact so that the water main may be turned off. Exposure to pathogens from sewer system breaks can occur, so have plans in place to mitigate this risk. Exposure to energized electrical wiring is a significant risk especially in combination with water main leaks.
Tornadoes Tornadoes are most frequently reported east of the Rocky Mountains during spring and summer months. There are warning systems available in most areas, but tornados can strike very quickly with little or no warning. According to FEMA, tornadoes travel across land at an average speed of 30 mph but may vary from stationary to 70 mph. Tornadoes are frequently drawn from thunderstorms, and thus, standard storm precautions should always be taken and the event should be postponed if a significant storm is developing. A tornado watch is announced when conditions are favorable for the development of a thunderstorm or tornado in the upcoming hours, but it is not imminent. A tornado warning is issued when a severe thunderstorm or tornado is occurring and sighted or imminent based on Doppler radar information. Event organizers that provide coverage in atrisk areas must be familiar with these terms and their implications. Locating the nearest public tornado shelter that can accommodate your event participants and an organized transportation plan to the shelter is strongly recommended. Public schools may be a good place to start when searching for tornado shelters; however, not all schools have shelters (3,10,11). Local public service agencies also can be a good resource for planning your response. Race organizers should consider cancelling events in the setting of a tornado watch that is felt to have a higher likelihood of producing funnel clouds, especially in locations that do not have immediate access to shelter. If a tornado warning is issued prior to the start of an event, the event should be cancelled and public announcements should be made if possible. If the event has already begun, Current Sports Medicine Reports
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participants should immediately seek shelter in the prior designated tornado shelter. If your medical team becomes involved in rescue attempts in the aftermath of a tornado, be sure that they are aware that a significant portion of injuries occur during these activities. They should not respond unless they have appropriate training in this activity and have the appropriate gear. Those that do not meet the criteria can man the medical tent to care for the victims that are found. It is always preferable to have public service agencies trained and equipped for rescue to perform those rescues and the medical team to provide care for those not needing urgent transport. According to FEMA, a study of injuries after a tornado in Marion, Illinois showed that ‘‘50% of the tornado-related injuries were experienced during rescue attempts, cleanup and other post-tornado activities. Nearly a third of injuries resulted from stepping on nails. Because tornadoes often damage power lines, gas lines, or electrical systems, there is a risk of fire, electrocution, or explosion’’ (3,11). Heavy Rains/Flash Floods Floods can occur through several different situations. Prolonged heavy or steady rains for several days or even hours can saturate the ground, causing slowly rising groundwater. Flash flooding can occur suddenly, given rapidly rising water along streams and low-lying areas. Sudden large storms that follow periods of drought can overwhelm storm drains due to debris. According to the FEMA flood preparation and safety guidelines, over the past 5 years, all 50 states in the United States have experienced flooding (2,12,13). Water mains and system pipes may break and create surprising and extensive flooding, like what occurred in UCLA in 2014, affecting multiple campus events and sporting venues including the newly remodeled Pauley Pavilion. Avoid placing your medical tent and equipment in areas when water pooling can occur, and be wary of storm drains nearby. Tent placement relative to storm drainage systems have actually created serious flash flooding within the main medical tent (author’s unfortunate experience). In this case, the site selected for the medical tent when the site plans were made placed the tent in the outflow area of several 6-inch pipes that drained a large parking lot. When there was sudden significant rainfall in excess of that expected, the drains filled the medical tent within minutes reaching a height of 1 to 2 ft, affecting medical operations and athlete care. At nonurban events, know your surrounding topography. Flash floods can be caused in hilly terrains by distant rains channeled into gullies and ravines, which in turn can cause a small, quiet stream to become a powerful and rampaging torrent. Course routes need to be reviewed for such risk and rerouted if necessary. Store important information in watertight containers. Make sure wiring and electrical components are at least 12 inches above potential flood elevations and higher if practical. Be ready to shut off breakers or generators if rising waters threaten electrical systems within your tent (2,12,13). Snow and Extreme Cold The authors recommend that consideration be given to postponing a sporting event if a severe snowstorm develops or is predicted with confidence or when wind-chill temperatures 174
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are low due to considerable risk for cold-related injuries. The American College of Sports Medicine recommends that coaches, athletes, and medical personnel know the risk factors, signs, and symptoms for hypothermia, frostbite, and nonfreezing cold injuries. The wind-chill temperature index should be used to estimate the relative risk of frostbite and with heightened surveillance of athletes and spectators in these environments. A protected warming area needs to be provided. Knowledge of local shelters or use of mobile shelters (or buses) should be considered and arranged. Individuals with asthma and cardiovascular disease can exercise in cold environments but should be monitored closely. Hypothermia is characterized as a core temperature below 35-C (95-F), which represents an approximately 2-C (35.6-F) fall from normal body temperature (5,7,8,14). Unnatural Disasters Sadly, acts of terrorism have escalated around the world, with sporting competitions being a target of some of these heinous crimes against society due to their high visibility. Rioting in ‘‘celebration’’ of championships and fighting during events, both often fueled by the effects of alcohol, have unfortunately seemed to become ‘‘the norm’’ in some locations, given their frequency of occurrence these days. Being nearly impossible to predict with any certainty, the medical team must be prepared to respond and assist as it would with any disaster. Events where alcohol is served and matches between political or ‘‘arch’’ historical rivals should prompt concern. Consider contacting the local Joint Terrorism Information Center or the local police department’s Terrorism Liaison Officer for perhaps useful information regarding terrorism threat when dealing with a larger or well-known event with high participation rate. Certainly, preevent discussions with local police and fire authorities should include the topics of terrorism and riot. As with preparation for other disasters, medical directors should consider the following with regard to acts of terrorism or violence and riots:
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allow participants from the event or medical staff inside your medical treatment areas. All athletes entering the tent should be checked in and tracked from time of arrival to time of discharge. Consider a stamp or sticker on the race bib once the athlete has been processed so that the medical team can easily identify someone that has not been processed. Have easily recognizable identification badges and clothing for the medical team. Have controlled access to your tents to keep anyone that does not have a reason to be there out of the medical tent. Maintain restricted access to the areas around your medical treatment areas and the supporting equipment such as supply trailers, generators, etc. Consider fencing for access control with a minimum of 20 ft of buffer around the medical tent and equipment. Train your team to be aware of packages, backpacks, or other items that are left unattended, and have a plan to respond to such a situation (in conjunction Unexpected Disasters at Organized Sporting Events
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with your public safety representatives involved with the event). The authors strongly urge the consideration of having physicians with advanced procedural skills on staff during high-profile events with the needed equipment to perform life-saving treatment. Have backup supplies as described at the beginning of this article available at the event, keeping in mind the treatments that can save lives in a mass casualty incident. ) Control hemorrhage (tourniquet or pressure) ) Acute coronary event (automated external defibrillator) ) Airway management ) Penetrating chest injuries (occlusive dressing for tension pneumothorax)
The following Web sites may serve as good resources when preparing for unnatural disasters:
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Terrorism FEMA brochure: http://www.fema.gov/ media-library-data/20130726-1549-20490-0802/ terrorism.pdf American Red Cross Terrorism Preparedness (with sections About, Prepare, Respond During, and Recover After). January 1, 2015: http://www.redcross.org/ prepare/disaster/terrorism The Consequences of Fire: from ‘‘A Reporter’s Guide to fire and the NFPA.’’ (Copyright National Fire Protection Association 2014). Web site: http:// www.nfpa.org/press-room/reporters-guide-to-fire-andnfpa/consequences-of-fire
CONCLUSIONS While it is impossible to prepare for everything that can occur, the authors hope that the information provided can function as a guide and stimulate thought for medical directors at sporting events on how to be better prepared to take initial action should the unexpected disaster occur. Working closely with public safety agencies both in planning and implementation of the medical plan can lead to a more coordinated and efficient response and potentially reduce the often ill effects of just such an occurrence.
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The authors declare no conflicts of interest and do not have any financial disclosures.
References 1. American Red Cross. Earthquake preparedness [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/earthquake. 2. American Red Cross. Flood safety [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/flood. 3. American Red Cross. Tornado safety [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/tornado. 4. American Red Cross. Thunderstorm safety [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/thunderstorm. 5. American Red Cross. Winter storm preparedness [Internet]. [cited 2015 Jan 1]. Available from: http://www.redcross.org/prepare/disaster/winter-storm. 6. Armstrong LE, Epstein Y, Greenleaf JE, et al. Intestinal injury associated with low-voltage electrocution. J. Trauma. 1981; 21:246Y50. 7. Armstrong LE, Epstein Y, Greenleaf JE, et al. American College of Sports Medicine position stand: heat and cold illnesses during distance running. Med. Sci. Sports Exerc. 1996; 28:iYx. 8. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine Position Stand: prevention of cold injuries during exercise. Med. Sci. Sports Exerc. 2006; 38:2012Y209. 9. Cooper MA. Emergent care of lightning and electrical injuries. Semin. Neurol. 1995; 15:268Y78. 10. Edwards R. The online tornado FAQ: frequently asked questions about tornadoes [Internet]. [cited 2015 Jan 1]. Available from: http://www.spc.noaa.gov/ faq/tornado/. 11. Federal Emergency Management Agency. Tornadoes [Internet]. [cited 2014 Nov 15]. Available from: http://www.ready.gov/tornadoes. 12. Federal Emergency Management Agency. Floods [Internet]. [cited 2014 Nov 15]. Available from: http://www.ready.gov/floodshttp://www.ready.gov/floods. 13. Federal Emergency Management Agency. The risk is real: flood preparation and safety [Internet]. FEMA F-684, catalog number 09107Y2 (06/14). [cited 2015 Jan 1]. Available from: http://www.regionalinfo-alert.org/wp-content/ uploads/2014/09/FloodPreparationSafetyBrochure_F684_062014.pdf. 14. Federal Emergency Management Agency. Winter storms and extreme cold [Internet]. Available from: http://m.fema.gov/winter-storms-extreme-cold. Accessed on January 1, 2015. 15. Federal Emergency Management Agency. Thunderstorms and lightning [Internet] Available from: http://www.ready.gov/thunderstorms-lightning. Accessed on January 1, 2015. 16. Kano M, Wood M, Kelley M, Bourque L. California Earthquake Preparedness Survey Report: Findings and Recommendations for Strengthening Household Resiliency to Earthquakes. Final Report to the Alfred E. Alquist Seismic Safety Commission and the California Emergency Management Agency. 2009. Los Angeles (CA): University of California at Los Angeles. Available from: www.community.fema.gov/connect.ti/AmericasPrepareathon/ view?objectId=3229616. 17. Xenopoulos N, Movahed A, Hudson P, Reeves WC. Myocardial injury in electrocution. Am. Heart J. 1991; 122:1481Y4.
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