Event Medicine vs. a Disaster: Three Lessons From the Astroworld Tragedy

Three key lessons have emerged in the aftermath of the Nov. 5 stampede incident at rapper Travis Scott’s Astroworld Festival performance in Houston, during which hundreds were injured and nine people lost their lives in one of the deadliest concerts in U.S. history.

“The big mistake is to assume nothing bad is going to happen. The other big mistake is to assume event medicine will handle it. The third mistake is to think, Well, we can just call 9-1-1. They’ll be here and be able to take it over,” notes David Persse, MD, medical director for the Houston Fire Department and an emergency medicine professor at the Baylor College of Medicine in Houston.

“You need to specifically plan based on the size of the event you think you're going to have and ask, ‘What are we going to do if things go bad?’ Even when someone gets hurt badly, it may still be just an ‘event.’ It becomes a ‘disaster’ when your resources are overwhelmed. If you expect event medicine to handle your disaster, you've set yourself up for failure.”

Persse points out that in large events such as the Astroworld Festival, “You need to create some depth within your emergency response system to be able to respond, whether it be adding units or preplanning to have mutual aid come in, just so your mutual aid partners are aware and are not getting caught flat-footed as well.”

A Unique Body of Knowledge

The Astroworld organizers had a contract with ParaDocs, an event medical services company that had provided services for previous Travis Scott concerts. Organizers also had a contract with a local 9-1-1 EMS provider agency that serves the Harris County Emergency Corps to provide ambulance support.

“When you are setting up an event like this, somebody needs to project the crowd size and what they think the medical needs will be for event medicine folks,” Persse says. “We need to respect that event medicine is a unique body of knowledge and experience. It's not just first aid tents.

“If you have a small event like a fun run, you probably can get away with some first aid tents. But if you're going to have a large event like this, the people you want staffing your medical infrastructure need to have some real experience and expertise.”

Persse notes that the Houston Fire Department’s experience with ParaDocs is “they do a very good job of taking care of the minor orthopedic injuries and easily managed allergic reactions and are very good at managing a lot of medical complaints to the point where people can either be returned to the event or they arrange for them to go home and not need to use ambulances and needlessly send people to the emergency departments.

“We need to have a level of respect for the people who do event medicine. We also have to recognize that event medicine and disaster response are two completely different things. When you plan for your events and know you’re going to have a certain number of people, you anticipate having a certain number of medical needs, and you plan for that.”

That means having a contingency plan “for when it goes horribly bad,” Persse says.

“The mistake some people make is that they say the event medical people will handle the disaster. It’s an unfair expectation of them. Many of us who are in emergency medical services are accustomed to and have a degree of comfort with taking care of critically ill and injured people, whereas well-experienced, highly trained medical professionals who are used to dealing with patients who don't have immediate life-threatening events are not comfortable with life-and-death situations and don't know how to manage emergency response, patient flow and triage, and provide critical care, all at the same time. We shouldn't expect them to be comfortable with that, nor should we expect them to be able to manage a large-scale event like that.”

Clear Lines

Plans need to include lines of accountability, and jurisdiction needs to be very clear ahead of time in terms of who’s going to be responsible for what, especially when it goes badly, Persse says.

“Event medicine is event medicine, not disaster response,” he notes. “The mistake a lot of communities make is they think their event medicine is going to be the local EMS system or a local hospital that's going to put up first aid tents and when a disaster occurs, that they will handle it.

“The other mistake that is often made is that they think if something bad happens, they’ll just call 9-1-1. But 9-1-1 is busy doing 9-1-1. In our community we don’t have a bunch of extra ambulances. These people are not sitting around twiddling their thumbs, waiting for something to do.”

The city of Houston has three EMS physicians on its SWAT team. One was on vacation during the Astroworld event, but another was embedded with SWAT and accompanied by an EMS fellow. Persse was on call for the remainder of the city that night and was at home when he was notified. 

“It went from zero to 100 miles an hour pretty quickly,” he says. “I got there quickly enough to go in with the second wave of ambulances.”

Persse notes that the reason ambulances had to exit through the crowd was to reach the nearest exit.

Initial reports of a security guard injected with an unknown substance were later debunked by Houston police. 

Of the injured, six were hospitalized, four were subsequently released, and two remained in the ICU as of Nov. 9.

Editor's note: This story corrects and updates an earlier version. EMS World regrets the error. 

Carol Brzozowski is a freelance journalist and former daily newspaper reporter in South Florida. Her work has been published in more than 200 media outlets.