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The mosh pit experience: Emergency medical care for concert injuries
The Mosh Pit Experience: Emergency Medical Care for Concert Injuries TIMOTHY JANCHAR, MD,*t CHRIS SAMADDAR,*::I:AND DAVID MILZMAN, MD* Effective planning is essential for medical personnel preparing to provide emergency care at mass gatherings. At large concerts where audience members participate in "moshing," crowd surfing, and stage diving, there may be a potential for a dramatic increase in injuries requiring medical attention. Injuries seen at emergency medical stations at 3 concerts, all with large mosh pits, over 4 event days were recorded and evaluated. Each event day had over 60,000 attendees. A total of 1,542 medical incidents (82.9 per 10,000) were reported over the 4 event days. There were 37% (466 patients, 25.1 per 10,000) of incidents related to moshing activity. Hospital transport was required for 2.5% (39 patients, 2.1 per 10,000) of medical visits with 74% (29 patients, 1.5 per 10,000) of those transported being for mosh pit-related injuries. When planning emergency medical care for such concerts with mosh pits, the potential for an increase in the number of medical incidents and injuries requiring medical attention and hospital transport should be taken into account for efficient medical coverage. (Am J Emerg aed 2000;18:62-63. Copyright © 2000 by W.B. Saunders Company)
" c r o w d surfing": passing an audience member overhead with the intent to throw them onto the stage, and "stage diving": running up on the stage and jumping into the audience with the hopes that fellow moshers will catch the stage diver. As alternative music rapidly gains popularity among the adolescent and young adult populations, large outdoor concerts featuring several bands are increasing, thus creating a new challenge for emergency teams who cover these events. The purpose of this article is to present the increase and different mechanisms of injuries at concerts where mosh pits are present so that medical personal responsible for covering these events may be adequately prepared.
METHODS There is an increasing role for emergency physicians to provide on-site medical care at mass gatherings such as sporting events, political congregations, and music concerts. 1 Published experience with these events documents the importance of planning and a well-prepared medical team to deal with the potentially large patient load and wide variety of patient presentation. 2 Although a large percentage of care provided at a mass gathering may tend to be for headaches, minor lacerations, and dehydration, particularly at outdoor events during the summer months, emergency teams should be prepared to deal with life-threatening problems such as acute myocardial ischemia, respiratory decompensation, and cerebral vascular incidents. 3,4 The planning for medical care provided at such events takes a different approach when the participants voluntarily participate in physically aggressive and potentially dangerous behavior. The rapid tempo and aggressive lyrics of many alternative bands, with inspiration from earlier punk bands, has induced a style of dancing known as "moshing." Moshing involves physical contact among concertgoers in a " m o s h pit": an area directly in front of the performing band. Participants push, shove, and kick each other and take part in
From the Department of Emergency Medicine, *Emergency Medicine Research Division, Providence Hospital, Washington, DC, tHarbor/UCLA Department of Emergency Medicine, Torrance, CA and the :l:lndianaUniversity School of Medicine, Bloomington, IN. Manuscript received February 12, 1999, returned February 20, 1999; revision received March 20, 1999, accepted February 28, 1999. Address reprint requests to David Milzman, MD, Emergency Medicine Research Division, Providence Hospital, 1150 Varuum St, NE, Washington, DC 20017. E-mail: [email protected] Key Words: Mass gatherings, emergency care, prehospital, injury, transport. Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1801-0014510.00/0
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All 3 events took place at a large outdoor stadium with a seating capacity of 68,000. The stadium is located in downtown Washington, DC, with attendees also coming in from Virginia and Maryland. All 3 shows took place during July or August. Average temperature for the 3 days was 77.2 °, with 1 day having intermittent rain showers. At each concert, 3 different stages were set up on the field level of the stadium with over 90% of attendees on the field level in front of the stages. The remaining attendees remained in the stadium seats. Two of the concerts were one-day events sponsored by a local radio station featuring 3 stages and over 20 bands, with each event having over 60,000 attendees. The third event was a two-day concert with over 30 bands bringing in over 66,000 attendees each day. The primary emergency medical station was located on the ground level near the stage. Medical care per event was provided by an average of 3 volunteer fourth-year medical students, 6 volunteer paramedics, 4 nurses, 2 emergency medicine residents, and 1 to 2 attending emergency medicine physicians. Ground ambulances were available to transport patients who required further care to a local hospital. In order for a patient to receive medical care, they were required to fill out a standard form containing information on age, gender, primary complaint, and mechanism of injury. Responsible guardians submitted this information if the patient was unable to. Treatment given, need for transport, and eventual disposition were added to these forms by medical students or nurses who were directly involved with that patient's care. One hospital, literally next door to the stadium, was used exclusively for receiving patients. If a patient was transported to the hospital, information on final disposition was obtained directly from the hospital. This information was documented and kept by the Department of Public Health which gave permission for the release of data. Institutional Review Board (IRB) approval for this study was waived and the project was approved by the DC Office of Emergency Health and Medical Services. Patient encounter data were then reviewed by the authors for types of injury or illness, medical treatment given, final disposition, and mechanism of injury, including mosh pit activity. Data were then manually entered into and analyzed using an Excel (Microsoft Corporation) spread sheet.
JANCHAR ET AL • THE MOSH PIT EXPERIENCE
RESULTS A total of 1,542 concert goers were seen at the emergency medical station during the 4 days for a rate of 82.9 medical incidents per 10,000 attendees. The average age was 21.0, with 60% of the visits by females. The ages ranged from 11 to 43, with only 9% of incidents occurring in patients older than 30 years. There were 35% of visits (535 patients) for complaints of headache with the majority treated with nonsteroidal antiinflammatory drugs (NSAIDS). There were 18% of visits (285 patients) for dehydration, exhaustion, or syncope, and these were treated with either IV or oral fluid replacement and rest. A total of 466 (25.1 per 10,000) patients were seen for injuries directly related to moshing activity. There were 17% of visits (161 patients) for lacerations and abrasions occurring in the mosh pit. Of visits, 20% (315 patients) were seen for musculoskeletal trauma sustained in the mosh pit, and 2.5% (39 patients, 2.1 per 10,000) were transported to a nearby hospital by ambulance for more extensive medical care. Of those transported to the hospital, 29 (74%, 1.5 per 10,000) had injuries related to the mosh pit, 24 (62%) were for musculoskeletal trauma sustained directly in the mosh pit, 5 (1.3%) were for lacerations directly from moshing activity, 5 (1.3%) were for syncopal episodes resulting from dehydration, and 5 (1.3%) were for alcohol or drug intoxication.
DISCUSSION For any mass gathering, a considerable level of health care planning is essential in order to ensure proper resources for the treatment of any health complaint. Among the many factors that must be considered when planning include the number and level of training of the available health care staff, the event facilities, the expected weather forecast, the type of music, and the expected crowd population. 5,6 These last 2 factors play a role in the behavior of the patrons during the event. The "moshing" that occurred during the events studied adds a new dimension in medical care planning for mass gatherings. Emergency medical services (EMS) personnel may expect an increase in the number of certain types of injuries, most notably musculoskeletal trauma and lacerations due to hazardous activity in the mosh pit. Most models describing medical care for mass gatherings fail to incorporate patron behavior into planning due to the lower number of injuries at events without mosh pits. Other studies of medical care at mass gatherings other than concerts with
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moshpits showed medical incidents to range from 0.20 to 5.23 per 10,000 at sporting events and nonmosh pit concelts. 7,8 A recent report of the medical incidents at the 1996 Olympic Games showed a rate of 22.9 patients per 10,000 in attendance. 9 Moreover, injuries from within the mosh pit are dominated by crowd surfing injuries requiring hospital transport. It must be taken into account that these transports for mosh pit injuries can take resources and time away from transporting more immediate life-threatening conditions such as myocardial infarction and respiratory decompensafion. Data from this study as well as others suggest that most patrons of these events do not require physician assistance for minor ailments, and true emergencies occur infrequently. 3 Of the 39 patients requiring hospital transport (2.1 per 10,000), 29 of these were directly related to mosh pit activity (1.5 per 10,000), weighing heavily in utilization of prehospital transportation services. Mosh pit activities and related injuries at large music events can be problematic for the medical personnel assigned for medical coverage if there is not proper planning for efficient treatment and transportation. Our analysis suggests that such injuries must be taken into account during the designing and execution of a proper emergency health care plan.
REFERENCES 1. DeLorenzo R, Boyle M, Garrison R: A proposed model for a residency experience in mass gathering medicine: The United States Air Show. Ann Emerg Med 1993;22:1711-1714 2. O Futde G, Forster L, Preisz P: Open air rock concert: An organized disaster. Med J Aust 1992;157:820-822 3. Thompson J, Savoia G, Powell R, et al: Level of care required for mass gatherings: The XV Winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991 ;20:385-390 4. Leonard R: Medical support for mass gatherings. Emerg Med Clin North Am 1996;14:383-397 5. Roberstson R: Planning for public events--an EMS approach. Emergency 1982; 14:39-43 6. Ounanian L, Salinas C, Shear C, et al: Medical care at the 1982 US Festival. Ann Emerg Med 1986;15:25-32 7. Spaite D, Criss E, Valenzuela T, et al: A new model for providing prehospital medical care in large stadiums. Ann Emerg Med 1988;17: 825-828 8. Sanders A, Criss E, Steckl P, et al: An analysis of medical care at mass gatherings. Ann Emerg Med 1986;15:515-519 9. Wetterhall S, Coulombier D, Herndon J, et al: Medical care delivery at the 1996 Olympic Games. JAMA 1998;279:1463-1468
" c r o w d surfing": passing an audience member overhead with the intent to throw them onto the stage, and "stage diving": running up on the stage and jumping into the audience with the hopes that fellow moshers will catch the stage diver. As alternative music rapidly gains popularity among the adolescent and young adult populations, large outdoor concerts featuring several bands are increasing, thus creating a new challenge for emergency teams who cover these events. The purpose of this article is to present the increase and different mechanisms of injuries at concerts where mosh pits are present so that medical personal responsible for covering these events may be adequately prepared.
METHODS There is an increasing role for emergency physicians to provide on-site medical care at mass gatherings such as sporting events, political congregations, and music concerts. 1 Published experience with these events documents the importance of planning and a well-prepared medical team to deal with the potentially large patient load and wide variety of patient presentation. 2 Although a large percentage of care provided at a mass gathering may tend to be for headaches, minor lacerations, and dehydration, particularly at outdoor events during the summer months, emergency teams should be prepared to deal with life-threatening problems such as acute myocardial ischemia, respiratory decompensation, and cerebral vascular incidents. 3,4 The planning for medical care provided at such events takes a different approach when the participants voluntarily participate in physically aggressive and potentially dangerous behavior. The rapid tempo and aggressive lyrics of many alternative bands, with inspiration from earlier punk bands, has induced a style of dancing known as "moshing." Moshing involves physical contact among concertgoers in a " m o s h pit": an area directly in front of the performing band. Participants push, shove, and kick each other and take part in
From the Department of Emergency Medicine, *Emergency Medicine Research Division, Providence Hospital, Washington, DC, tHarbor/UCLA Department of Emergency Medicine, Torrance, CA and the :l:lndianaUniversity School of Medicine, Bloomington, IN. Manuscript received February 12, 1999, returned February 20, 1999; revision received March 20, 1999, accepted February 28, 1999. Address reprint requests to David Milzman, MD, Emergency Medicine Research Division, Providence Hospital, 1150 Varuum St, NE, Washington, DC 20017. E-mail: [email protected] Key Words: Mass gatherings, emergency care, prehospital, injury, transport. Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1801-0014510.00/0
62
All 3 events took place at a large outdoor stadium with a seating capacity of 68,000. The stadium is located in downtown Washington, DC, with attendees also coming in from Virginia and Maryland. All 3 shows took place during July or August. Average temperature for the 3 days was 77.2 °, with 1 day having intermittent rain showers. At each concert, 3 different stages were set up on the field level of the stadium with over 90% of attendees on the field level in front of the stages. The remaining attendees remained in the stadium seats. Two of the concerts were one-day events sponsored by a local radio station featuring 3 stages and over 20 bands, with each event having over 60,000 attendees. The third event was a two-day concert with over 30 bands bringing in over 66,000 attendees each day. The primary emergency medical station was located on the ground level near the stage. Medical care per event was provided by an average of 3 volunteer fourth-year medical students, 6 volunteer paramedics, 4 nurses, 2 emergency medicine residents, and 1 to 2 attending emergency medicine physicians. Ground ambulances were available to transport patients who required further care to a local hospital. In order for a patient to receive medical care, they were required to fill out a standard form containing information on age, gender, primary complaint, and mechanism of injury. Responsible guardians submitted this information if the patient was unable to. Treatment given, need for transport, and eventual disposition were added to these forms by medical students or nurses who were directly involved with that patient's care. One hospital, literally next door to the stadium, was used exclusively for receiving patients. If a patient was transported to the hospital, information on final disposition was obtained directly from the hospital. This information was documented and kept by the Department of Public Health which gave permission for the release of data. Institutional Review Board (IRB) approval for this study was waived and the project was approved by the DC Office of Emergency Health and Medical Services. Patient encounter data were then reviewed by the authors for types of injury or illness, medical treatment given, final disposition, and mechanism of injury, including mosh pit activity. Data were then manually entered into and analyzed using an Excel (Microsoft Corporation) spread sheet.
JANCHAR ET AL • THE MOSH PIT EXPERIENCE
RESULTS A total of 1,542 concert goers were seen at the emergency medical station during the 4 days for a rate of 82.9 medical incidents per 10,000 attendees. The average age was 21.0, with 60% of the visits by females. The ages ranged from 11 to 43, with only 9% of incidents occurring in patients older than 30 years. There were 35% of visits (535 patients) for complaints of headache with the majority treated with nonsteroidal antiinflammatory drugs (NSAIDS). There were 18% of visits (285 patients) for dehydration, exhaustion, or syncope, and these were treated with either IV or oral fluid replacement and rest. A total of 466 (25.1 per 10,000) patients were seen for injuries directly related to moshing activity. There were 17% of visits (161 patients) for lacerations and abrasions occurring in the mosh pit. Of visits, 20% (315 patients) were seen for musculoskeletal trauma sustained in the mosh pit, and 2.5% (39 patients, 2.1 per 10,000) were transported to a nearby hospital by ambulance for more extensive medical care. Of those transported to the hospital, 29 (74%, 1.5 per 10,000) had injuries related to the mosh pit, 24 (62%) were for musculoskeletal trauma sustained directly in the mosh pit, 5 (1.3%) were for lacerations directly from moshing activity, 5 (1.3%) were for syncopal episodes resulting from dehydration, and 5 (1.3%) were for alcohol or drug intoxication.
DISCUSSION For any mass gathering, a considerable level of health care planning is essential in order to ensure proper resources for the treatment of any health complaint. Among the many factors that must be considered when planning include the number and level of training of the available health care staff, the event facilities, the expected weather forecast, the type of music, and the expected crowd population. 5,6 These last 2 factors play a role in the behavior of the patrons during the event. The "moshing" that occurred during the events studied adds a new dimension in medical care planning for mass gatherings. Emergency medical services (EMS) personnel may expect an increase in the number of certain types of injuries, most notably musculoskeletal trauma and lacerations due to hazardous activity in the mosh pit. Most models describing medical care for mass gatherings fail to incorporate patron behavior into planning due to the lower number of injuries at events without mosh pits. Other studies of medical care at mass gatherings other than concerts with
63
moshpits showed medical incidents to range from 0.20 to 5.23 per 10,000 at sporting events and nonmosh pit concelts. 7,8 A recent report of the medical incidents at the 1996 Olympic Games showed a rate of 22.9 patients per 10,000 in attendance. 9 Moreover, injuries from within the mosh pit are dominated by crowd surfing injuries requiring hospital transport. It must be taken into account that these transports for mosh pit injuries can take resources and time away from transporting more immediate life-threatening conditions such as myocardial infarction and respiratory decompensafion. Data from this study as well as others suggest that most patrons of these events do not require physician assistance for minor ailments, and true emergencies occur infrequently. 3 Of the 39 patients requiring hospital transport (2.1 per 10,000), 29 of these were directly related to mosh pit activity (1.5 per 10,000), weighing heavily in utilization of prehospital transportation services. Mosh pit activities and related injuries at large music events can be problematic for the medical personnel assigned for medical coverage if there is not proper planning for efficient treatment and transportation. Our analysis suggests that such injuries must be taken into account during the designing and execution of a proper emergency health care plan.
REFERENCES 1. DeLorenzo R, Boyle M, Garrison R: A proposed model for a residency experience in mass gathering medicine: The United States Air Show. Ann Emerg Med 1993;22:1711-1714 2. O Futde G, Forster L, Preisz P: Open air rock concert: An organized disaster. Med J Aust 1992;157:820-822 3. Thompson J, Savoia G, Powell R, et al: Level of care required for mass gatherings: The XV Winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991 ;20:385-390 4. Leonard R: Medical support for mass gatherings. Emerg Med Clin North Am 1996;14:383-397 5. Roberstson R: Planning for public events--an EMS approach. Emergency 1982; 14:39-43 6. Ounanian L, Salinas C, Shear C, et al: Medical care at the 1982 US Festival. Ann Emerg Med 1986;15:25-32 7. Spaite D, Criss E, Valenzuela T, et al: A new model for providing prehospital medical care in large stadiums. Ann Emerg Med 1988;17: 825-828 8. Sanders A, Criss E, Steckl P, et al: An analysis of medical care at mass gatherings. Ann Emerg Med 1986;15:515-519 9. Wetterhall S, Coulombier D, Herndon J, et al: Medical care delivery at the 1996 Olympic Games. JAMA 1998;279:1463-1468