Medical care at a mass gathering music festival

Mass gathering music festivals are increasing in popularity. In 2019, 26% of adults in the UK visited a music festival [1]. Projected medical emergency case numbers as well as an ever-present potential for mass causalities during such music festivals, necessitate the presence of well-organized, professional, on-site medical services [2]. Achieving valid estimations of patient presentation rates (PPR) and medical emergencies is necessary for effective logistical planning; however, incidence rates are associated with both event-dependent factors, such as music genre and visitor demographics, and environment-dependent factors, such as weather and landscape [3, 4]. Reported PPRs vary extensively among mass gathering events, from 0.7 per 1000 visitors to 72 per 1000 visitors [5, 6]. Prediction of the incidence of medical interventions across music festivals is, therefore, inaccurate; however, it remains unclear if and to what extent, PPR, TTHR and epidemiology change year by year at the same festival.

Most studies reported patient presentations at a given music festival for only 1 or 2 years [6‐10], and/or focus on special topics, such as the mental health of visitors or drug use [6, 7, 11, 12]. Longitudinal observations from music festivals over several consecutive years are sparse [10]. It is unclear (yet important for predicting medical demand) if the epidemiology of health related events at an annual music festival changes over the course of several years. The main aim of this study was to determine longitudinal changes in PPR, TTHR and pertinent epidemiology over a 7-year span at a large pop and electronic music festival in Austria which draws up to 200,000 visitors per annum. Since event-dependent factors do not tend to undergo major changes from year to year, potential longitudinal changes in PPR and TTHR may possibly be associated with environment-dependent factors. Therefore, the influence of weather on epidemiology was explored.

A total of 1,003,500 persons visited the festival between 2011 and 2017. Of 18,684 medical records 13,759 were included. Due to either incomplete data (2605 presentations, 14%) or multiple entries (2320 presentations, 12%) 4925 cases had to be excluded. The cause for these multiple entries was the method of documentation: Every time a patient was moved to a new location (e.g., from outpost to main post), a new entry was made by the dispatch system. As such, double entries were merged into one entry consisting of all available information.

The median (minimum to maximum) PPR and TTHR were 12.01 (9.33–20.86) per 1000 visitors and 0.57 (0.40–1.06) per 1000 visitors, respectively (Table 2). The PPR and TTHR changed significantly over the years, although demographics of the festival population, such as sex and age, did not change by year. Table 3 shows the frequencies of chief complaints. Most of the presentations (65%) were due to pain (of any origin). The most common reason for pain was of traumatic origin (70%) (Table 4). Trauma was the number 1 reason for presentations, accounting for 6466 presentations (47%). Most of those trauma patients had pain as their chief complaint. Most traumatic presentations over the years were caused by blunt trauma (57%), followed by penetrating trauma (20%). Most penetrating trauma was caused by pieces of metal simply lying on the ground. No gunshot wounds were recorded. The most common causes of blunt trauma were falls and blisters on feet and hands. A small fraction of blunt trauma due to fights was recorded. The majority of both blunt and penetrating trauma was categorized as either NACA 1 or 2 and was treated on-site. In 20.9% of the traumatic presentations, the cause was not documented.

Only 5% of presentations (746 over 7 years) were due to intoxication, with the majority of these (86%) being due to alcohol. The remaining 14% (104 cases) were due to recreational drugs.

The NACA scores were not equally distributed over time (p < 0.01). There were no NACA 6–7 cases documented during the study period. Although the number of visitors did not decrease, the absolute number of NACA 3–5 emergencies decreased by 95%, from 73 to 3, over the years (p < 0.001) (Fig. 2). After linear regression analysis, the total number of visitors was not observed to have any significant effect (p = 0.52) on the number of medical emergencies, even when stratified for NACA 1–2 and NACA 3–5 cases (Fig. 3).

Regarding the organization of on-site emergency medical care, the main first aid pod was staffed with up to 3 EPs and up to 8 EMTs. During concert hours, a third EP was at the site. Additionally, 30–55 EMTs were deployed at all times in mobile first aid squads, to patrol the festival area. The minimum number of personnel on site did not differ over the years, although additional volunteer EMTs were on site irregularly.

Our study is the first to examine the medical emergencies within the visitor population of a large music festival over 7 consecutive years. To our knowledge, only one study has investigated a college music festival over a 4-year period [10].

Our data show that between 9.33 (2016) and 20.86 per 1000 visitors (2011) were in need of emergency medical services, resulting in 0.40 (2017) and 1.06 per 1000 visitors (2013) being transported to hospital. These numbers varied significantly between various years. The PPRs that we observed landed squarely within the PPR ranges described in the literature [5, 6]. Concerning TTHR, reported numbers ranged from 0.71 to 1.8 per 1000 visitors [5, 6].

There is no standardized and evidence-based method of planning the emergency medical care for a music festival. Certain precautions are recommended but the organization is widely done by local emergency medical services [14]. Calculation of the number of personnel or amount of equipment needed relies on local laws, previous experiences and protocols such as the Maurer formula in German speaking countries, which relies mainly on the number of visitors, the location and type of event [15].

Remarkably, there was no significant correlation between the number of visitors and patient presentations. The theory that this is caused by some kind of ceiling effect, occurring when the time spent for queuing up for a small wound dressing becomes too long, was disproven by analyzing NACA I–II and NACA III–V cases separately, following the assumption that a severely sick or injured patient will not have to wait in line. Even in the NACA III–V group, no correlation between visitor numbers and patient presentations was found.

This lack of a correlation raises important questions for future event planning. It may be that the necessary personnel calculated from Maurer’s formula tends to overestimate; this requires revaluation in future studies. When considering what may influence the PPR and TTHR of the Frequency Festival, the weather forecast seems to be more important than the number of visitors. In the year 2011, there were significantly more insect related cases; this included all kinds of bites/stings/etc. In that year, a lot of wasp nests were found in the area, including the camping grounds. In the following years, the organizers had those nests removed before the beginning of the festival. This simple action proved effective. The number of insect related incidents sank significantly. This is one of the precautions which led to a relatively low number of patient presentations. In accordance with the literature [12] we could show that prevention strategies reduce the number of patient presentations in the group in question.

In our study, the reported percentage of alcohol related and drug related emergencies was only 5%; this is a considerably lower number than has been reported elsewhere in the literature for similar events [12, 16]. This may be either founded in the high proportion of basic traumatic emergencies, or the possibility of sleeping off the intoxication at the site.

There were no cardiac arrests seen during the observational period. A cross-check with regional news outlets/publications around the dates of the festival brought no further information about possible deaths occurring at the festival. Although literature analysis showed that mortality is reported to be a factor in festival visitor populations [2, 17, 18], no deaths were reported in this sample. The reported causes of death in the literature include mass casualty events subsequent to trampling, structural collapse and acts of terror. Grange et al. report that all deaths in their sample of over 400 occurred at classical concerts, although the PPR was highest at rock concerts [4]. Other authors have reported deaths due to intoxications at various festivals [8]. In our reported sample, the number of intoxications was quite low, which—in combination with visitors’ relatively young age and the friendly atmosphere—could have contributed to zero deaths being reported.

There were significant differences and a high variance in both PPR and TTHR over the years. Contrary to our expectations, the number of visitors did not predict the number of patient presentations. Ambient temperature was associated with the number of heat related emergencies, but not with the number of cold related emergencies. Prevention strategies, such as the removal of insect nests, resulted in significantly fewer insect related emergencies.