David 0:06

Lovely. So, picture a festival medical tent at 9 o'clock on a Saturday night. 20,000 people on site. The provider worked out the cover months ago using a formula on one page of a guidance document. Crowd of this size, therefore this many first aiders, this many ambulances. And right now that tent is drowning because the formula never asked who the crowd was. What the weather did at 4 o'clock or what happens when the headliner runs late. This is the argument we're unpacking today. Welcome to the show, my guest Owen Davis, a founder of Better Event Medicine and author of Medical Provision for Events and Crowds, Evidence-Based Practice. So, great book, 500 plus pages, nearly a thousand peer-reviewed sources cited. And the simple, quite uncomfortable message for our industry: most event medical planning is done on gut feeling, and the gut feeling doesn't scale. Owen, welcome. Hi, great to be here. Nice to have you. Yeah. So, the first question really: your background is an unusual one for this field. You're a chartered marketeer and you've spent years making data-driven decisions across B2B and B2C markets. How does that commercial data first mindset end up producing an evidence-based book about event medicine?

Owain 1:31

Yeah, I mean it's a very fair question. Um, so when you think of a marketer, obviously people would often think about, you know, pretty adverts or maybe mad men, and it's not really like that for me. So I've always been a product marketer. So that isn't about selling things, that's about well, what do we make? What should it be? And how do we best meet the user needs um for whatever the particular product might be? Um, so I've been I've done that in different industries, but last 15 years or more I've been doing it in healthcare. I've done things like triage, clinical decision support, um, including leading systematic reviews of evidence and data and trying to get to uh match up the evidence with um what happens um you know in in uh you know for the user, for the user experience. So, and across all that time, my 20 odd years of doing that, I've been spending my weekends doing medicine at events. So I've worked at more or less every level. Uh I've worked on my own in a field watching people race lawn mowers around, true story, um, through to command roles at some of the UK's largest events. Um so for me, uh you I I do input to guidance. I've been um working on the Purple Guide team for a number of years, doing the medical section for Purple Guide. Uh and more recently I've been one of the authors on the new Event Healthcare Standard or National Event Medicine Standard. Um so but I overall, several years ago, I've been growing frustrated with that that lack of evidence and loads of examples of the wrong cover. You um people be familiar with that conversation. Well, you know, can we just have like an ambulance and four first aiders, please? Well, maybe, but that may or may not be right for you. Maybe it's too little, maybe it's too much. I can't say. Um, you know, the whole robot work around uh, well, this is what we had last year. Um, and to me it's very, very frustrating as someone who really likes evidence and uh you know good user experience and good outcomes. So uh you know, probably about three and a half years ago now, I decided to combine some of my skills in that research, those systematic reviews, the user-centred product design, and event medicine, which I've you know, all uh real interest areas of mine. Um so I started off and I thought I was gonna write some short guides, um, but it somewhat grew, and I realized that anything less than a full textbook is gonna miss out massive chunks of information. Um, you know, so I set about doing it the best way I yeah, I can and you know reviewing thousands of bits of uh peer-reviewed information, you know, journal articles, textbooks, um, and you know, as you said, not nearly a thousand of them are referenced in line in the actual book itself. Um, but you know, it's a really, really challenging area, so people need to prepare for those things, and it's challenging because there's at least three sets of things you need to prepare for. So there's the expected presentations, that's what you think you're going to get.

Speaker 1 4:26

Definitely.

Speaker 4 4:27

Oh, these you know, we're gonna get some headaches and some blisters, and that's true of almost any event. Um, you've got the what's reasonably reasonably foreseeable at that event, so you have um you and that that really really depends on the type of event, and even within music, you know, what you reasonably foresee at a dance music event is different to what you'll see at a uh a rock concert. Um rock concerts you'll get moshing, dance events you'll get MDMA intoxication, those sorts of things. It's it's different. Uh and then yeah, you do have to give some mind to what some people call the uh black swan events, the things that well you probably couldn't have reasonably foreseen it, but you've still got to be ready. Uh I mean some people would argue that black swans aren't aren't uh you know there's not there's nothing that should have been completely unforeseeable. Um but yeah yeah, I mean the probably the best thing about uh black swan events is it was uh it was uh coined to say you actually you're worrying about things that don't exist. And it took and when it actually later turned out the black swans do in fact exist.

Speaker 5:25

So when they saw them, people were quite yeah, the the phrase existed before people knew black swans existed.

Speaker 4 5:34

Um yeah, so organisers and event medical providers work on the experience of things they have seen, and maybe they've been lucky, you know. So if you're qu covering equestrian cross-country, you might have only seen bruises or yeah, maybe a broken bone or two over you know runnings for several years. And and great, I mean that that would be that would be normal. Um but last weekend alone, at the point we record this, two people died at separate equestrian events. Um yeah, so that's something clearly it's foreseeable. You m you need to know that that's something that could happen at your event.

Speaker 2 6:07

And were those could they have been planned for those two deaths?

Speaker 4 6:11

Could it but it could have been I'm not familiar with the with the details of of the care. I'm sure they got you know as good a care as those providers were able to give. Um But you know, you've got to be prepared that serious injury you know things are gonna happen at that sort of event in a way that you're anticipating different things at a question cross-country to what you might be at a marathon. I mean, uh you know, loads of runs take place, you know, every weekend you'll see organized runs. And yeah, the same thing applies, is that you know, you probably won't have a cardiac arrest at the finish line of your event, but I can guarantee that a couple of events this year will. You know, and you don't know if it's yours or not. Um and even medical providers fall into that trap. You know, you need to be able to evaluate the risks individually for for the for the event, not just rely on you know what it is that you think it you might have seen last year or those sorts of things.

Speaker 2 7:01

Yeah, yeah, great. Yeah. Well in in the book you draw our attention that anyone in the events industry kind of recognises the and we've seen this more and more really the organizers running a business, margins are extremely thin. I mean, we've seen some events cancelled, haven't we, this year because the margins are so thin? Um and the medical cover can look like a compliance tick box. Um, meanwhile, the provider is carrying the clinical risk. So, how does the book bridge that gap? And what's the case to the organiser that event-based planning protects the bottom line and and of course the brand?

Speaker 4 7:37

Yeah, absolutely. Event medicine is often a bit of an afterthought, just something, oh, we've got to get that done. Um, and the provider does carry some of the risk, but as an organiser, if you haven't done your due diligence and done a proper job of assessing whether this was the right cover for you, um, then you can still be um liable for that. So, you know, people can make claims against your event because you didn't pick a good enough medical provider or didn't specify enough medical cover. Right. Um, you just look at the Manchester Arena inquiry, the criticism was there of the medical provision on the night, but most of that was was reserved for the for the uh organizer and the venue for not provisioning enough care. They did not take the care they should have taken um to make sure that this yeah, to make sure that that there was sufficient cover in place. Um and you know, you and maybe maybe some of your listeners might be familiar with uh Reason's Swiss cheese model. Um yeah, the idea that you know you can think of risks through a series of Swiss cheese slices with the holes. And you know, if the risk travels in a straight line, if it hits a hole, it goes through to the next layer. So it it needs all those all those holes to line up for a risk to become a problem. Yeah, a theoretical risk to be a problem. Um but medical provision it you know makes up at least two of those layers in terms of uh how you think about this for it for your event. Um and away from the actual risk piece, you there's good peer-reviewed evidence that um medical cover can improve the satisfaction with the event, can improve event loyalty, can improve word of mouth recommendation, and you can be sure that people have a bad experience, do talk about it on the internet and to their friends, and you know, I I went there and it was awful. Yeah, that that sort of thing gets around. And especially if it's a really bad outcome. Um, you know, I you I you know I know of festivals and things who have who are folded after a death. You know, so whole music festivals and they they have a death and the following year they just can't run. You know, it it it's that damaging to a brand. Um, you know, even if the cover was good, you know, that's that you know that's the that's the risk you that is the risk, always. And of course you've got things like your licensing, yeah. So yeah, will the safety advisory group and or council or whoever looks after your regulates your events, you know, will they will they license your event again if if it's found that your cover was substandard? And then you get to things like Martin's Law obviously coming in. Now that's specifically focused on terror risk, but you know, it you know the medical cover definitely plays a part in that. Are you adequately preparing for these for these major you know actually foreseeable problems?

Speaker 2 10:16

Yeah, there's things like um it will come into it, won't it? Because let's say there's an evacuation at an event and there's casualties from an acid attack or anything. You need to have enough medical cover within the confines of the building, don't you, to look after those casualties because the ambulance service might not even be able to get to you at that point.

Speaker 4 10:38

Yeah, absolutely. I mean, um you know when minutes count, um you um the you know when when sorry, when seconds count, the emergency services are only minutes away. Um, you know. For these mass casualty and major instances, you know, the prime responder is going to be your in-house team for a at least a period, and yeah, that will depend on what's what sort of event it is and where you are. If your event is on um Parliament Square in London, well actually there is loads of resource knocking around there from all the saturated services. Um if it's if it's a festival in the middle of nowhere, you might be half an hour from the very first NHS ambulance arriving. Now, all the evidence suggests that good outcomes at mass casualty and major instance, um, the best outcomes are associated with having all your priority one patients in hospital within 30 minutes. Now, if your NHS ambulance first one isn't there for 30 minutes and they will set up a command position, then you you're your the likelihood of that coming out well isn't isn't great.

Speaker 2 11:40

Taking your point as well about um reputation of a venue, um we talked a bit about this yesterday, that certainly since COVID people seem to be more anxious, there is more levels of anxiety around p when people go to venues like this. And even if they don't use the medical services that are there, if there's a visible presence, you know, and a good representation, that can ease the stress and actually be a print preventative measure, can't it, without actually calling on them.

Speaker 4 12:09

Yeah, absolutely. Early intervention is is important. So actually, what happens is you know, there's really good evidence that medical posts and things need to be well positioned in high traffic areas, but not but but not where there's crowds, you know, avoiding some of the problems that uh Key Still talked about yesterday. Um you're trying to make sure that you know if it's there and it's well signposted, you know, your signs should be up in the air above people's heads, they should be green and white, they should use the international symbols, all of these things are associated with people seeking care earlier, which means that that you head off the problems. So, you know, take outdoor festivals, you know, heat can be a major problem. And actually, it's much, much better if those people come and seek help when they're feeling a bit unwell, as opposed to when they actually become really unwell. You know, that's a massive difference to it. So positioning your medical centres properly works you know, works very much in the uh in the favour of the organiser and trying to make sure it's you know it's there, it's high profile. And you're right about the anxiety. I mean, a major trend for the probably the past four years maybe has been the a rise in people reporting that they've been needle-spiked. Now, um that you know that's certainly music festivals, this is. Um, but I mean the the period evidence is that there's no real evidence that this actually happens, but people worry about it an awful lot. Um, you know, so I'm not saying I'm sure people it's angry people in the comments maybe, but actually, you know, the the evidence is by and large this isn't this isn't a widespread problem, but the the anxiety about it is, and those people patients present with real problems, you know. So, you know, making sure that you have a medical team there ready to deal with it. Um, you know, some festivals had problems with uh you know reputational risk, getting, oh well, I'm not gonna go there. I've I've heard that loads of people were you know were needled spiked, or uh yeah, and I've I've worked at festivals where the rumour goes round that that some people have been stabbed in the venue. Now, I and I I know it's not true because we'd have seen them, you know, and you end up having these conversations in the control room and the medicenters just going, you know, you know, we have we're getting feedback that people have been stabbed, and you you security, you have your you know, security, your CT, the operator, and go, No, absolutely, yeah, we're we're pretty certain that's not happened, but that's the rumour. And that rumour you know causes anxiety, that anxiety causes you know real problems for some people, panic attacks, you know, it can cause crowd movements, so you know, back to Keith Still again, you know, you it's a it's a major, you know, you don't something real doesn't have to happen. You know, whether it's someone setting off a banger, uh you know, someone screaming because their mate pushed them, um, because it was funny, but everyone thought that they'd been stabbed, you know, those are things, real things that can cause an impact.

Speaker 2 14:42

We're having a laugh about the hor the police horse leaving a deposit which caused the crowd to do that.

Speaker 4 14:47

Yeah, exactly. So, yeah, but yeah, it the the the problem doesn't have to be real for it to cause to for it to cause a real issue for the event.

Speaker 2 14:55

Absolutely, yeah. Thinking a little bit about uh tables now, this is probably the most confrontational idea in your book, and you published a blog, a blog about it this week as well, the reference table. Uh now you mentioned that you work for the you do a bit of work for the Purple Guide as well. So just take that apart for us, you know, that uh what you were talking about there.

Speaker 4 15:15

Yeah, so I mean I you know I say I've I've been um on the advisory group for the medical for Purple Guide for a number of years, but Purple Guide itself came about after some bad cases, and particularly there was uh Monsters of Rock, which is at Donington uh airfield in 1988, and there were a number of deaths there. Um yeah, people came to realise well they didn't really have good medical planning. Um so yeah, the reference tables, you know, that there's been Purple Guide's been through sort of two major styles and uh you know an a load of iterations of of that. And it uses it used many of the right measures, you know, so you know, number of people and um you know some of the risks, the season, that sort of thing. Um but you know the evidence is pretty clear that reference tables are poor at predicting needs um for medical pieces, um, often use opinion over evidence and quite quickly out of date. Part of the problem is that anything that you know reference tables are by their nature heuristic, by which I mean rule of thumb. You know, you've got you've got means you've got to take shortcuts, you've got to put things in wide bands because there are simply too many variables to do a neat table, essentially. So people who who do like lots of stuff stats crunching and things will be f familiar with concepts like combinatorial explosion, which is a kind of a fancy way of saying, well, there's just too many variables. I can't I can't make sense of the data. I'm trying to, you know. So you see this in things like triage as well. You know, if you take too many things into account when you're doing if you're trying to automate triage, for instance, if you take too many things into account, the the accuracy goes down, not up.

Speaker 3 16:52

Right.

Speaker 4 16:52

And it and you know, and it's kind of the same here. So you've you've got to strike a fine balance between using evidence and data, and then taking that with the you know the experience and the the you know the knowledge that you know good experienced event planners have. Um you know, and the result of having that is that reference tables meet lead to some organisers having far, far too much cover and others having nowhere near enough. Uh and going back to your earlier point, you see the organizers will, you know, your arguments, we have these things going, well, you know, Purple Guide says I only need this, uh so that's all I'm paying for. Okay. I mean, maybe it's right, maybe it isn't, but you know, doing a proper assessment for the event is is the right thing. And for that reason, you know, some time ago we we've taken the Purple Guide took the decision to take the reference tables out, um, you know, due with much you know um you know criticism from the industry, um, you know, to be honest. Yeah, people were going, well actually this is this is um you know we we relied on those, and which is great, but relying on something that isn't accurate, it it also isn't also isn't the right answer.

Speaker 2 17:59

Kind of removes the ability to think through the process, don't it? And your event you're just going across and down and and so on.

unknown 18:08

Yeah.

Speaker 4 18:08

Yeah, absolutely, yeah. That that process. So again, uh you know, um going to my fanboy uh listening to Keith Still yesterday, um, you know, um it's yeah, he said that you it should be a red flag if you see just generic generic copy and paste used in the plan. And that's true of medical cover as well. Every event needs its unique assessment. So even an event that's been running a long time, variables change. So you know the amount of medical cover you need is affected by event type is by far the biggest influence on um what we call patient presentation rate. So that's the amount of people per thousand that need help. But it's also things like weather. So every one degree Celsius increase in temperature creates about a 10% increase in patient presentations.

Speaker 2 18:55

All right, wow, interesting.

Speaker 4 18:56

It's a really, really big effect. I'm sure you can see that you know, in in fact, it's in less than 10 degrees because it's cumulative, less than 10 degrees of of weather increase, and it's very important at the moment, it's quite hot here, it's been quite hot everywhere. Yeah, so if you've run it, if you've run your event every year at twenty at about twenty-three, twenty-four degrees, and this year it's thirty-two degrees, you've put you may well see nearly double the amount of patients. And that's you know, even if you kept everything else the same.

Speaker 2 19:23

And the nightmare is one day it could be twenty degrees, the next day it might be thirty-two in it in the UK.

Speaker 4 19:32

Absolutely, and that and that's the sort of thing that you you need to be planning for, and you know, taking your risk into account, actually having that information about about the heat is really, really important. And actually, so you know, so you know, it's difficult, and I appreciate it's difficult for providers as well, but you know, so you know, if you're planning your event, you get your medical cover sorted, say, let's say six, seven, eight, nine months in advance, and you you want a fixed quote, which is great, apart from the fact that we you know we've now come you know to the you know to the event for this year, and you know that your medical provider should be looking at it going, yeah, we're in an unprecedented heat wave. Um, maybe we are going to need to up your number. You know, and organisers, you know, on their thin margins, don't want that. I I understand. Um, but that you know those are those are exactly the sort of thing where you're going to get people starting to complain, going, well, it was dreadful, you know, and it and it feeds into a whole narrative in their head as around, well, there wasn't enough shade, where was the water, where you know I mean even uh water is a great example. So um where where there's plenty where there's plentiful free water, um it's good for patients or for not getting patients, but uh um not having readily available free water is associated with approximately a doubling of patient presentations. So you so you know it may sound like a good go, oh it's quite expensive to get this free water and get it all tested, get all the things done, but it you know actually you could save that back on your medical costs.

Speaker 3 20:57

Yeah.

Speaker 4 20:57

Um half as many people.

Speaker 2 21:01

So that kind of brings us to the sort of the next point, like the the sort of so if you've done a medical plan six months ago, printed off, sent off in a PDF, emailed, approved, whatever, that brings us to the point about digital uh documentation, and that's your other life really, isn't it? In digital products and things like that. Um but your book keeps coming back to the one idea that live data leads to the best decisions. Now, a bit of disclosure for me here, safety we have all documentation on a live platform. Um so feel free to push back on any of that. But um, on the event day, what does the difference look like between a medical manager working from a clipboard and a radio in a six month old plan and one working from live synced documents on a mobile device, for instance?

Speaker 4 21:52

Yeah, so I mean, so yeah, data and documentation both really, really important parts of delivering um you know on the medical computer. for an event. And again, this is proportionate to the size of event. If you're running a village fate for for or you know a village tea dance for 200 people, that's different to running a festival for 60,000. Of course it is. But you having that information you know always helps. So you know a good medical plan should be based on you know the three parts which is predicting the expected presentations. So that is you know what we've just talked about there is how many people do I expect to be sick. Because that's going to dictate how many people you need. So we know again from the data that on average a patient takes about 20 minutes to treat. So it stands to reason that if you get three patients that's an hour of staff time. So you know you can pretty quickly work back from what from one to the other to work at how many staff you need. Now obviously presentations can be you know different um you know it can be different patterns they can be different um severities. So patterns an interesting one so you know as an example for multi-day events on a four-day event you expect you know a number of presentations on day one whatever that might be you expect day two to be double that and you expect day three to be triple what day one was and then day four likely to be back to what day one was again. And that's all to do with this sort of you know with the various patterns to do with you know all sort yeah all sorts of things play into that but that's that's a typical pattern at these sort of events. Yeah and obviously that's impacted by those live things like temperature. So if you're going to predict expected presentations well you know live data's going to tell you actually well with the where forecast has changed we've got you know this is going to be hotter than we thought.

Speaker 3 23:33

Yeah.

Speaker 4 23:34

You need to predict the utilization so that's going to be well how many people are likely to need to go to hospital again you can do that with data but it will be impacted by some of the things that um you maybe outside your control. So at music festivals a a major predictor of transport transfer to hospital right so how many people if you have taken an ambulance and go to hospital um is things like the drug consumption. So you know and again you get things like you know bad batches and again I mean maybe counterintuitively there's really strong evidence that the stronger your drug enforcement um the worse the outcome for patients. So you get more people presenting and they're sicker. If you you know if you put more searches in more more drugs dogs uh yeah more enforcement you actually find higher rates of um you know drug uh drug related injury so very hard for an organizer in that in that respect yeah but yeah but but that but that sort of intelligence about what's happening there that you know your your plan needs to update you know yeah you're you need to be updating your plan in real time almost to say well this this is what's happening now um and that also counts for things like pollution you know um whether that's actual you know pollution from a factory chimney but also dust and things like that so particulate rates yeah about pollen count would you factor in a pollen count absolutely um external things like wasps you know so insects also a major driver of outdoor events of um you know biting insects stinging insects right and this is all stuff that you know should be feeding into what you do um because you know you you don't just need the plan so you've got your presentations your utilisation and then you resource for that demand and obviously you may or may not have that your resource may or may not be fixed mostly it is because actually it can be quite difficult to call in well actually I need 10 extra people can you find them will will the organiser pay for them all all difficult things but yeah so in addition to your actual plan you need things like a a surge management plan. So what happens if you know or sometimes when demand is higher than we thought it would be because that's going to happen sometimes you know best data in the world you do your planning all based on evidence but sometimes it will just be higher based on things that you didn't know or you m maybe you could have predicted but again quite often you see that the medical teams and like the safety teams and those sort of things are not necessarily working as closely as they could do or ought to. Yeah so you stuff like dust and insects and pollen are all things potentially that the organiser and the safety team could have done something about to prevent the medical problems. But you know very rarely do you hear those conversations happening in advance again okay well you have you got a plan for you know um tractors towing water bows as to to tamp to damp down the pile so the dust doesn't come up have you you know can the organiser talk to the farmer next door and make sure he cut down the rapeseed before the uh before the festival happens that's he's probably gonna say no but you know but you you you you can at least you can at least you can at least plan for it and know that there's a field of rapeseed there. And document it yeah absolutely right of course yeah um yeah so all all these things feed into it and then you know that gives you a you know that workable medical plan and there's also things like you you mentioned earlier about you know well what happens you know you might need extra space if you if if if loads of people suddenly go down maybe it's a mass casualty maybe it's a bit below that but it's you know loads of people suddenly go down with heat. Now I've definitely seen plans which will say okay well you know you know if if the OpenStack Centre is overwhelmed we'll set up a sort essentially a forward post in one of the bars. Does the bar manager know that? If the medical if the medical if the medical uh team leader walks in and goes cool um we need to clean this out and we does does he know what to do? Do the staff know what to do? Are they going to help? Are they are they gonna more likely half an hour of confusion will will in sh will ensue where there's radio messages going back and forwards on seven different channels as as nobody really knows that that was supposed to happen and what when what they should do about it if what it does. Yeah so yeah that surge demand plan well yeah you things you can do you know you can start to do proactive messaging so you know good medical planning you'll have some of these messages pre-planned so you know things like heat pollen all those sort of things go you know a lot of festivals or things like that have apps now you know and you can do push messaging or you can put it on the screens or you can announce it on the Tanoy or yeah whatever whatever your method is it doesn't matter but actually you can have pre-prepared text and images you can have pre-prepared scripts you all those things now that's not the medical provider's job per se but they need a strong input into it and about the things that you want to have planned say actually we are see you know ladies and gentlemen we are seeing a particularly high demand at the moment um caused by caused by dust on site you know if you you know if you you know if you can help yourself there are sinks by all the toilet blocks where you can you know wash down your own faces um if you you know if you still need medical help our our team are here and they're by Blue Gate or you those that sort of proactive messaging and it helps um stop the panic. So again I'm gonna go back to Keith Still yesterday and he was talking about well what difference does it make that one guy at the front on stage going okay everyone I know the power's gone out but we're gonna sing a cappella for a bit. Yeah yeah but it's it the the same thing applies to all sorts of medical situations. There's not just crowd movement it it's that it's that planning and that's all fed by data. So you know that's data from weather data from traffic even data about your medical demand how many people are in the medical centre right now data about the crowd flow you know so if you've got if you've if you've got crowd experts on there um all this data you know gives you a much better chance of giving you know people who might become ill or injured a good experience you know you know reflects well back on your event and you know that sort of thing and then that extends on so the other thing that you know every event really ought to have every big event certainly is a is a patient access plan. So this is something you rarely see but it's it's really really important. So that's the idea that yeah patient access plan is how you're going to easily identify your patient. Now imagine your field full of 2000 people your patient's there in the middle somewhere and that's you know that's fine but how how are you going to find them? You know some events have spotters up in towers some have drones all those sorts of things I've sat there watching CCTV I mean uh good example I was in the control centre for a festival and we got we got called by the local NHS ambulance service in fact to tell us that there was a card deck arrest just off site um yeah so just just off the the perimeter line of the of the the event um there was a cardiac arrest uh they had reported and they were probably 20 25 minutes out um so I was sat in the uh sat there and we the also with me was the uh police drone operator so he immediately got the drone in the air and and and actually yeah we we we could find it because it was quite complicated there were steps and you know and you know with within 30 seconds we'd located the cardiac arrest with a bystander doing CPR and um you know I was able to guide the ambulance out of the festival site and tell them exactly okay turn left now because that is yeah well yeah next left and though yeah yeah so yeah and we got a um you know uh yeah and the return of spontaneous circulation so yeah the our uh our intervention by our um by our team you know um you know got got their heartbeat back which is great so yeah but that's yeah that's that lot integration of live of live things um yeah you need to do early assessment so you need to get a team out to find out well you to assess them but you know even in a crowd you know the the the most you can get you know so the recommend in all the literature pretty much it's recommended you should be able to get your medical team to assess a patient on site in about four minutes or thereabouts that's the recommendation now it's always gonna be possible depends where they are but yeah in the main event site four minutes that is 200 metres in in real money so the the walking speed in crowds four minutes you 200 meters so that means that where you position the medical centre really important and actually yeah crowd change crowd dynamics will change that so when you've got that information coming in about crowd flow um yeah it's a good example like agricultural shows if you've ever been to one you quite often find they shut whole walkways so that the tractors or the cows or the llamas can come through to do their parade in the main ring. Yeah so what you find all of a sudden is there's a big barrier cutting off cutting the site in half basically and you can't get through yeah. So obviously good planning means that actually that live data in your in your updated you go well you should know when that's going to happen and actually maybe you need to move people equipment maybe a vehicle they should be the other side of that obstruction before the obstruction happens because you know it's happening. Yeah yeah um so the importance of live live documentation really so some of that is pre-planned documentation you know because you've got a schedule but the live bit is actually well you know quite often well cows is delayed 20 minutes because the judging hasn't finished in the cattle shed. Yeah yeah so yeah actually yeah but the difference that makes on live data is is really really big. Now obviously if you are you know if you're doing these things on the fly with just your radio in in the med centre you can you can make notes you can have bits of paper lying around um but it doesn't necessarily tell you what's happening now and it it and it's not also not a shared view.

Speaker 2 33:03

So uh at at the point you know you and can you guarantee that the uh that the chief steward on on cattle is going to tell you that the cows is running late and therefore the parade is delayed and you sometimes you get that information sometimes you don't well uh you've given us a good idea there actually because um with the medical plans that we have on safety docs which are live obviously they're updated right up to the event they can be downloaded in case there's uh you know mobile phone issues or something but um for one um client we actually bill in a weather it's weather into the medical plan so in the top left there was a box showing the latest weather now we could have one for pollen not not done that before but then but then that document also feeds into other documents as you mentioned doesn't it like the patient access plan other documents so really if you're able to create something which is a master plan medical plan but then when that changes it also changes the other documents like risk assessments like Keith was talking about yesterday you a risk assessment should be specific to the venue and not cut and paste so if you if somebody collapses you know like right in the middle of the crowd that's one risk assessment if they collapse by the medical tent it's less of a risk you know so you've got to have different risk assessments so it's important that when one document changes the other changes as well and like you touched on you might not be able to do anything about that in terms of bringing more staff instantly but it can certainly go on to like the pre-shift briefings can't it you know so the the team events we've got this situation we've not got the extra medical cover but what can we do to mitigate any potential need for extra resources and that's yeah I mean it also means working across the other providers on site so security's a big one.

Speaker 4 35:00

Now you know um you you get things yeah so there's good evidence that sometimes security don't always do the right thing for the patient because they they expect the medical team to turn up quickly. And again it's fine they know where the patient is but that's got to be communicated from from them to the controller and you know I mean most professionals are a bit better than the public at the we're by a green tent I I can see a tree um you know you've got to describe where the patient is then you send someone out and all those sort of things actually you know there's pretty reasonable evidence that you know security seems well if you find a patient well if if they're if they're awake and talk you're talking well you're actually better if the security team bring that patient to the nearest first aid post because they they should know where that is. Or if they're in the crowd may maybe security could help just drag them drag them out where the medical team can find them. And if they are you know if they're there and it's really serious maybe they're not breathing well actually they need to start CPR you know and you know there's again there's evidence that you know security don't start CPR even though even though they're all trained uh the all the SIA staff are trained um they don't start CPR because oh the medical team will be here in a minute and that yeah that's that's bad for outcomes um but having that having that shared understanding of what everyone expects from each other and you know some security will be willing to do some things and some won't but yeah there is you know there's evidence that that where you work together and you have those shared plans so actually that that should be you know the medical team should be feeding into what the what the security plan is um and and vice versa. I mean there has been a bit of a rise in companies trying to do both and you know I have I have thoughts about that certainly but you know there is there is evidence that sometimes that's that's um that that doesn't produce the best outcomes especially if they're trying to do both at the same time um you know some people have quite a negative reaction to security guards rightly or wrongly um yeah so when when you have a problem the security guard approaches you um to help you treat the problem or what looks like a security guard to you you know maybe maybe but they because they're in a security uniform you know you you you know that that they they're less likely to approach for help early they're like all these things that you know it's worse outcomes you know so I'm not saying one company can't provide both because of course they can and they could be competent but having having some thought about that that division is helpful sometimes.

Speaker 2 37:12

One thing that you cover in the book which is quite a a stark statistic and it's going to be more of a I was seeing it more of a problem especially especially when budgets are tight and that is we don't need to hire all the radios because we'll just use mobile our mobile phones. We've got a WhatsApp group you know for all the stewards so on but you make the point that um mobile phone infrastructure fails in over 60% of cases because the crowd overloads the network at exactly the moment responders need it.

Speaker 4 37:47

Yep absolutely yeah I mean that's a problem both on site and off so you know you've got you know so any of the sort of GSM communications that you know that's something that you need something better. So again a lot of people use these sort of GSM radios still but they they they send like burst messages over GSM but again those can those those can also be affected and they can go down and it also it's a problem for getting the help. So you know say something really bad's gone the the stage has fallen down the first thing that will happen is you know um a hundred people will hit will hit 999 um and you know all of a sudden local 999 capacity starts getting spread out and then the local you know ambulance and fire and police controls will all of a sudden become overwhelmed with calls. Now if you're yeah if I'm the commander I need to pass my Meta message. I can't get through on 999 because it's blocked. So the one person who you needed to to tell the emergency services what was happening can't get through if you're relying on 999 to do that which a lot of people do. You need a better way. So yeah absolutely trying to get that trying to get that information through is is is really important but you know on site absolutely yeah you need robust communications you know and again there are ways you can do it you know um you know like people don't think actually medical you know medical teams at almost every event need some sort of internet and that's you know some of that's is is communication and emails and passing information but other part you know other parts is like looking up drug you know looking up toxins maybe or checking you know checking uh protocols for a for a rare presentation that sort of thing so you know and yet it's not often not you know and actually a good number of providers now use electronic patient records. So actually if they haven't got good stable dedicated internet that they've got to be able to do this in a way that also doesn't expose that private information. So chances are that especially a big event your medical provider is going to need a dedicated their own internet piece which works. And if they use yeah if they're using sort of mobile phone based um you know mobile phone based uh you know radios and things like that well maybe they would work if the Wi-Fi was working but you you have uh you know both compensated and uncompensated events so uncompensated major incidents where the infrastructure is affected. So if the stage falls well all the repeaters which were mounted on that stage and just below have just gone out of commission. So you've now got a massive black spot in in your comms.

Speaker 2 40:19

And that kind of brings us on to the next question because major incident declared then we've thought we've taught aren't we methane which major incident declared exact location the type the hazards the access number of casualties emergency services required that's a lot of information isn't it um other radio under extreme pressure we've all been there repeat can't you know you can't pick up the radio message there's a lot of noise going on have you thought much about this how maybe digital platforms could help in that sort of situation I'm not saying we've got an answer but you know yeah no absolutely there's definitely things in there I mean part of it is that actually most most of methane is already is already known to you so you know those sort of things are designed for instance where your uh responder of any of the emergency services turning up at you know uh a coach a coach full of nuns which just crashed off a bridge um you know or whatever other casualty storyline you wish to insert in the in the uh in the problem but actually we know a lot of this in advance so your documentation in your planning you should this a lot of this is sort of pre-done and we also know the type of major instance that are most likely to happen at events in fact actually some which kind of only happen at events um yeah so actually you know stuff like um you know some of the crowd problems it's very much an event problem you you you that doesn't it doesn't you know it can happen in other places for s for some reasons but by and large it's very much an event problem you know crowd crowd movement injury crowd crush injury yeah very much associated to events and we know we know the proportions roughly in which they appear so again also you know uh terror same same piece Martin's law yeah we know that events are the place where that is likely to happen yeah that that that is what is targeted um yeah the same even the same for things like heat and mass heat injury you know people don't tend to get heat injured going about their everyday business because they all they'll go to the shop they'll come back will feel a bit hot I'll sit down on the sofa I'll be fine but um but you know in an event you're out in the blazing sun possibly and you you can't modify your routine or do the things you'd normally do so your coping mechanisms reduce and maybe go away.

Speaker 4 42:28

So you know we know we know major uh mass casualty and major incidents are absolutely foreseeable at events of pretty much all sizes you know and you know both organisers medical providers safety officers all need to accept the fact that you know it is reasonably foreseeable that it will happen. Maybe it won't happen in your event and you know I hope it doesn't happen at your event. But you need to be ready in case it does um you know but you know uh you there's uh you know it was a trend a while you know you called funny t-shirts and uh I had I definitely had a friend who um uh had a you know uh an ambulance funny t-shirt was like you know I don't want you to hurt yourself I just want to be there when you do that was the um um but it's a bit like that for V for this for this medical planning I don't want a uh yeah mass casualty incident at any event you know that's you know and obviously safety officers and you know organisers do as much as they can to make sure that doesn't happen. But you know sometimes it will it'll happen at someone's event this year. You know and maybe it's yours maybe it isn't and I hope you know but you need you need to prepare the fact that is foreseeable. These things aren't black swans they're not you know it's not oh I couldn't possibly so Manchester Arena inquiry again yeah they should have foreseen that some sort of major issue like that could have occurred. It didn't have to be a suicide bomber. It could have been a structural collapse it could have been um you know all sorts of it could have been a fire it could it could have been you know um the gas tanks behind the bar exploding it does it any of these things it could Be. But that that's you know, but they hadn't sufficiently planned for the fact that oh it's foreseeable that something would happen. And especially events where you have lots of temporary infrastructure, so structural collapse doesn't happen very often in out in the the real world. Happens quite a lot of events because it's all rigged temporary in in situ. Um, you know, um yeah, lots of things happen at events in ways that they don't happen elsewhere, even things like uh cardiac arrest. So you it's you know overall per sort of hundred thousand people, it's four times more likely at an event that you'll get someone have a cardiac arrest than it is when people just go about their normal everyday business. Um which is which which is a lot, it's it's a huge difference. Um yeah, so you know you need to have defibrillators, you need to have it it's reasonably foreseeable because it is higher risk. As soon as people come out to their event, coping mechanisms go down and the and you see this rise in the baseline level.

Speaker 2 44:57

Yeah. And it it really, I mean, we've talked about documentation being available in an emergency, but we shouldn't really be relying on having documentation when something happens. We should be prepared, shouldn't we? So people should be familiar with the processes, the the documentation, the venue, the you know, the event. They should all be familiar, they should have walked the walk, they should know exactly what's to do when those situations happen, shouldn't they?

Speaker 4 45:23

Yeah, absolutely. So you know so the event plan shouldn't say, you know, commander will pass the meter message to the emergency services, and you know, and you can do this obviously exact location. Well, you know, the well the exact location necess isn't necessarily you know, name a festival at this postcode. Yeah, it it might you know if you've planned well, you go actually, well, it can happen here, it can happen there, you know. If it's a bus crash into a crowd, well that's going to happen at the transport centre. That's over here. So what does that what does that look like? How do how is that different? But you can have all this pre-prepared. Yeah, so you can have your your your A MR files were actually going, okay, so something something has happened on stage two. Okay, stage two, right, exact location is this. Access points are here, here, and here, which is different to what happens if it's on the main stage, it's different to what happens if it's in the camping area. Yeah, so these that that generic look at what happens is different, and that goes back to the patient access plan as well, you know. So, you know, big a big site, you know, patient access plan is both for routine operations and for major instance, but well, yeah, you you have a patient. A patient could happen anywhere on your site, and they could be awake and talking, they can be walking, they could be unable to walk, they could be lying down, they could be unconscious. How are you going to get to and then move that person from any one of those places? And what if there's lots of them, you know? What if a bit of the stage has collapsed and it's and it's hit, you know, four of the um of the sound operations crew? You know how are you going to get to that? What's the yeah, what's the plan? You know, it doesn't have to be wildly detailed, but just some thought about oh okay, we're gonna have a real problem if it happens there, because you know, that's the do I have to send a vehicle off-site? Um sometimes you have to send a vehicle off-site from the medical centre, round the perimeter road, and back in a different gate. Uh that's quite common on some of these things, because you don't want to send vehicles through the you know, last thing you want to do on almost any event is send a vehicle through the the public areas, so you send it around the back, but you know, do the gate staff know? Do you know do you know do the you know does the stage manager know? Or any of these things? And actually that goes back to that shared documentation and that shared view of risk. Trying to make sure that everyone has has what they need.

Speaker 2 47:37

Which is kind of why what we promote with the platform that we use, that people have got it in them on the mobile devices, they can read it when they wake up at night, when they get up in the morning. It's there long before the the start of the event, and then they're familiarising themselves with all the the types of things that you mentioned. So thinking about um practical things then. So somebody's listened to this podcast on the way home, hopefully. Um the book your book arrives the next day. What's the first thing they should do with the book? Because 500 pages, a thousand, you know, peer-reviewed studies. How can they use it practically?

Speaker 4 48:16

So the whole book is designed to be practical. So yeah, it's not the only book on event medicine out there, but there are some others, but most of them take quite a sort of academic approach. I've deliberately tried to make this practical. So you'll see lots of things like you know, examples of good practice, examples of poor practice. You know, actual steps you you can or should take. So, you know, I think for me, you you know, if I wanted one thing, it would be people to understand that that that structured approach to medical needs assessment and that structured approach to delivering a medical plan. So you don't need to read every single word, I mean, yeah, please do by all means, and yeah, yeah. Um, but you know, actually, you know, understanding that that three-step that that yeah, that three-step method of assessing risk for medical needs, really, really important. And yeah, that delivery, you know, looking through some of the bits and seeing where it applies to their events. That's the uh yeah, that's the long and short of it. So you know, um safety teams, planners, that sort of thing, yeah, they're gonna be mostly interested actually in the first section, which is all about the planning, the numbers, yeah. How do I know if I've got the right the right medical cover, where it's gonna go, what and that sort of thing. Um yeah, the the second bit's all about standards. So actually that's being oh actually, well, what should a what should a sign on a first aid post look like? You know, what you know, what colour should my medical staff be wearing and why is it green? Um Yeah, that um all yeah, all these sorts of things. And again, some of the things they might might not have thought about. Um and then the third section is about that management. So that's about the that's all the things about you know, we've talked about some things like communicating with external services and you know pre-preparing medical messages for surge demand, and you know, planning surge demand in general, those sorts of things. Um section three, you know, and how how do you how do I how do I do a patient access plan? You know, what what what do I do to make one? How do I make it and what should it say? You know, so that's the sort of third section, and the fourth section is all about the mass casualty of major instance. Um, you know, you know, you and actually again, everyone, whether you're an organiser or a safety officer or a medical provider should be familiar with some of that, some of those pieces to say, actually, what is it that we need to prepare for? Yeah, and I you know, try and reiterate every time it, you know, major incidents are foreseeable at events. Doesn't matter your size, you know, and again, there is a level of scaling, but you know, the you know we've we've yeah, if we've if we've seen anything is that actually you know major incidents can happen even at some relatively you know small and insignificant looking events, um, yeah, especially when you look at um especially to the continent for some of um you know the sort of more terror type attacks, you know, ramming attacks on farmers' markets and things like that. Now, if you're the organiser of a farmer's market, you go, well, that's fine. Well, people come, yeah, we're here, we're here with our tents in the square, yeah. We've got you know 50 people selling stuff from you know 20 stands, and you know, a couple hundred people will be wheeling around. Okay, great, but that you know that's uh unfortunately the world we live in is that well that actually well what happens what happens if that goes really badly wrong? Now, you know, there for that farmers' market, well it's make it it probably isn't proportionate to have a major instant commander thing standing by. Of course that's not proportionate, but that doesn't mean you can't have done some planning you know about your meeting message, well what's you know, have your prompt sheet, well, yeah, yeah, and you know, I I'd forgive them for having having a single version of that for for a farmer's market to say, well, actually, what is our exact location? What what is the what is the type you you know all these things planned out in a butt you know how how what is the entry exit point? All those sort of things planned out in advance, yeah. Um but as soon as you get more complicated, you might need to have several versions or those sorts of things.

Speaker 2 51:51

Well we're gonna put your link to your book um in the description. Um I think I got mine on Kindle, but you can get hard copies as well, can't you? Things like that. And and what about if people wanted to reach out to you? I know you're on they can connect with you on LinkedIn, can't they? Um is there any other support that you offer or anybody that wanted to reach out to you or yeah, absolutely.

Speaker 4 52:11

I talked to lots of people. I mean, you know, I have a massive driver to try and make you know the industry a bit better, so that's yeah, that's you I'm really passionate about trying to help people do um you know do better with their event medical provision. So you know, got a website at uh better eventmedicine.co.uk, better event medicine all one word. Um yeah, and there's a few blogs on that there that only recently started doing some blogs on it. Um and obviously that's also links to the book. Um and then yeah, we're you know, always happy to talk to people and you know, try and you know give a little bit of a little bit of advice.

Speaker 2 52:44

Yeah, yeah, brilliant. Good. Well, thank you, Owen. It's been really informative, as we as we thought we would it would be, we knew it would be. Yeah, so Evidence over instinct. So plan on the model, run on live data, and assume the network will fail at the worst moment, because it will. Owen, thank you. Uh the book link and episode notes are in the description, alongside our previous episode on crowd science and the work of Professor Keith Still. Um, two books that belong on the on the same shelf, I'm sure you'll agree, yours and and Keith. So um thank you for joining us, Owen, and uh we'll we'll communicate again. But uh thanks for your time and all the best in your endeavours.

Speaker 4 53:25

Thank you very much, and stay safe at all. If you would like a free trial of safety docks, please visit safetydocs.org.