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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 17-22

The role of emergency medical services providers during mass gathering: Hajj Season 2019


1 Department of Emergency Medicine, King Abdulaziz Medical City; King Abdullah International Medical Research Center; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 Department of Emergency Medicine, King Abdulaziz Medical City; King Abdullah International Medical Research Center; College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
3 King Abdullah International Medical Research Center; College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
4 King Abdullah International Medical Research Center; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia

Date of Submission20-Sep-2021
Date of Acceptance04-Apr-2022
Date of Web Publication2-May-2022

Correspondence Address:
Ali S Al-Shareef
Department of Emergency Medicine, King Abdulaziz Medical City, P.O. Box: 12723, Jeddah 21483
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_136_21

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  Abstract 


Background: Mass gatherings are worldwide events, and the Hajj season is considered one of the significant mass gathering events that happen annually in Makkah city, Saudi Arabia. Medical preparation such as preparation for transportation, training, and medical staffing for mass gatherings at existing sites has been discussed. Aims: This study aimed to assess the role of emergency medical services (EMS) providers during Hajj Season 2019 and the preparedness of the EMS system through providers' perspectives. Settings and Design: A cross-sectional survey using a questionnaire has been conducted in Makkah during the Hajj season 2019, which took place in Mena valley and Arafat. Methods: Convenience sampling from two major institutions (the Saudi Red Crescent and the National Guards Hospital, EMS Department) was used. The inclusion criteria included emergency medical specialists and emergency medical technicians. Statistical Analysis Used: The data were analyzed using JMP. Data for continuous variables were presented as mean and standard deviation if normally distributed, otherwise median and interquartile range were used. Data for the categorical variables were presented as frequencies and percentages. Results: The majority of EMS providers were male in gender and almost half of them were emergency medical technicians with a diploma qualification. Most of them had specific training before Hajj such as basic life support. However, the majority reported the use of medications during transport and training are areas that require improvement. During Hajj, the majority of the EMS providers do ambulance decontamination. Busy shifts and lack of workforce were the main reasons for working more than 12 h per shift. Conclusions: This study offers important recommendations for improving the EMS system's preparedness during Hajj, which include more workforce coverage as well as improved providers' qualifications and level of training. Furthermore, this study provides a recommendation to change the scope of practice to treat and release in the majority of cases rather than unnecessarily transport to the hospital. This study urges the importance of collaboration between agencies to facilitate the EMS system.

Keywords: Emergency medical services, Hajj, preparedness, Saudi Arabia


How to cite this article:
Al-Shareef AS, Al-Thaqafy MS, Almalki AA, Alwael SS, Almetairi AM, Najmuldeen RF, Shirah BH, Alsulami MA. The role of emergency medical services providers during mass gathering: Hajj Season 2019. Saudi J Health Sci 2022;11:17-22

How to cite this URL:
Al-Shareef AS, Al-Thaqafy MS, Almalki AA, Alwael SS, Almetairi AM, Najmuldeen RF, Shirah BH, Alsulami MA. The role of emergency medical services providers during mass gathering: Hajj Season 2019. Saudi J Health Sci [serial online] 2022 [cited 2022 Oct 3];11:17-22. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/1/17/344482




  Introduction Top


Mass gatherings are worldwide events that occur for many reasons such as concerts, sporting events, or religious events. They can happen spontaneously or by planning, which restrain the resources of the country that is hosting that event.[1],[2] Hajj season is considered one of the significant religious mass gathering events that happen annually in Saudi Arabia. Every year, Saudi Arabia receives between one to two million pilgrims from all over the world during the Hajj season.[3]

Emergency health-care providers play an important role during Hajj by providing medical care from basic to advanced interventions. During Hajj, there are many medical conditions that can be treated on-site. Paramedics in particular have a major role in treat and release that resulting in decreasing the overcrowding in hospitals. Treat and release refer to on-site (at the scene) treatment of a patient by a responding team without transporting that patient to a healthcare facility. Treat and release provide adequate immediate medical care that will result in a functioning emergency medical services (EMS) system. During on-site treatment, emergency medical providers have the ability to treat the medical conditions with many kinds of medical interventions, such as administration of medications, minor surgical interventions, airway management, and wound dressings that will help in improving the patient's outcome. Since Hajj is an annual event, certain health conditions are usually seen such as heat stroke, hypoglycemia, dehydration, trauma, and upper respiratory tract infections. Thus, emergency providers should be well-prepared for these common cases. There are no studies, in terms of Hajj, that assessed the emergency providers' preparedness for the common medical condition seen during hajj days.[4],[5]

The preparation and planning before any mass gathering event are crucial for its success. The preparedness of mass gathering includes different aspects such as patient care services, public health, terrorism attacks, medical resources, coordination and collaboration with agencies, and standardized protocols. However, the preparation and planning differ from one event to another depending on the event type and size. There are a number of factors that affect medical preparedness during large-scale mass gatherings such as concerts, Olympic Games, and Hajj. These factors could be due to the lack of standardized protocols, therapeutic guidelines and, medical resources.[6],[7],[8],[9] Previous studies regarding Hajj were mainly focused on patients' conditions, treatment, and infection control rather than focusing on the preparedness and competence of the EMS system. Therefore, there are currently no published studies on this matter. Our study aims to assess the role of EMS providers during the mass gathering in the Hajj season 2019. The purpose was to investigate the preparedness of the EMS system and to determine if on-site treatment by emergency providers affects transportation and how the social demographics might alter the system outcomes. Furthermore, this research also aims to explore the efficiency of decontamination and infection control that affects transportation. In addition, we assess the response time during a response and how it affects the patient outcomes during Hajj.


  Methods Top


This study was an analytical cross-sectional survey using a questionnaire that was designed depending on the research objectives. It was conducted in Makkah during the Hajj season 2019, which took place in Mena valley and Arafat through convenience sampling from two major institutions (the Saudi Red Crescent [SRC] and the National Guard hospital, EMS Department) that lasted 5 days. The inclusion criteria included emergency medical specialists and emergency medical technicians. The sample size of the inclusion criteria consisted of 185 (n = 185) respondents. The exclusion criteria were emergency physicians and nurses. Institutional Review Board approval was obtained before starting the data collection. Prior to distributing the questionnaire, informed consent was obtained from each participant. Subject confidentiality was maintained throughout the process of this research. An online questionnaire was used for providers who could not fill out the hard copy questionnaire. We tested the validity and reliability by taking consultations from experts. For reliability, we used a pilot test by selecting 15 subjects from the selected sample. The variables were: Social demographics, training, resources, vaccinations, and precautions. Medical management questions regarding on-site treatment were collected. The data were analyzed using JMP. Data for continuous variables were presented as mean and standard deviation if normally distributed, otherwise median and interquartile ranges were used. Data for categorical variables were presented as frequencies and percentages.


  Results Top


In total, 245 providers participated in this study. The demographic information of the sample is shown in [Table 1].
Table 1: Social demographic characteristics of the participants

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Approximately 170 (70%) of the emergency medical specialists and emergency medical technicians were male in gender. The mean age was 32 ± 6.48 years. 102 (42%) of the providers were emergency medical technicians, which means they have a diploma degree. Moreover, the years of experience of the participants were 7 years (median = 7 and interquartile range = 8). The past medical history showed that the majority of participants 212 (87%) received the required vaccines before working in Hajj [Table 2].
Table 2: Past medical history of the participants

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Most of the participants took the influenza vaccine 193 (78.8%) and meningococcal vaccine 192 (78.4%). Most of them had training before Hajj 205 (83.7%), and the majority of agencies require specific courses to be able to work in Hajj 200 (81.6%). The most required courses were Basic Life Support (BLS) 186 (75.9%) followed by Advanced Cardiac Life Support 116 (47.3%) and Pre-Hospital Trauma Life Support 105 (42.9%). 160 (65.3%) of the participants reported that they have enough resources. On the other hand, the scarcest resources were medications 64 (26.1%), medical equipment 60 (24.5%), and personal protective equipment 55 (22.5%) [Table 3].
Table 3: Experience of the participants

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Gloves 238 (97.1%) and masks 225 (91.8%) were the most used personal protective equipment by the emergency medical providers with every patient they encounter [Table 4].
Table 4: Approaching to patient by the participants

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Of the paramedics and emergency medical technicians, 118 (63.8%) decontaminate the ambulance after every patient transportation. In addition, 83 (44.9%) administer medications. Only 64 (34.6%) providers would treat the patient on-site. On the other hand, 79 (42.7%) participants would transport a patient in a life-threatening condition to the nearest facility in case of closed roads [Table 5].
Table 5: Approaching a patient in case participants are paramedics and emergency medical technicians

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165 (67.3%) of emergency medical providers worked more than 12 h during Hajj days, and the reasons behind that were busy shift 100 (40.8%) and lack of workforce 86 (35.1%) [Table 6].
Table 6: Working hours of the participants

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The majority of participants agreed that the EMS system during Hajj needed improvement 196 (80%). Most of the participants admitted that lack of manpower 43 (17.6%), coordination with agencies 42 (17.1%), and providing specific roads for ambulances 36 (14.7%) are the areas that require improvement [Table 7].
Table 7: Improving the emergency medical system as perceived by the participants

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  Discussion Top


This is the first study that assessed the role of the EMS system in the mass gathering during Hajj and examined the preparation and planning of the system from two different institutions, (SRC Authority [SRCA] and National Guard hospital). The findings we analyzed regarding this gathering have clarified that the preparedness of the EMS system needs to improve. Moreover, the study results indicate that the majority of EMS providers were male emergency medical technicians.[10] They can provide only limited care in comparison with paramedics specialists. Moreover, the majority of SRCA employees are emergency medical technicians, and they represent most of our study's sample size since they have a larger number of emergency medical providers than the National Guard Hospital.

During the mass gathering, infection control is very crucial. This study showed that the majority of participants received vaccines before working in Hajj. Although this data has been collected through a survey, not medical evidence, the percentage is considered high compared to a previous article, which was 38%.[11] Moreover, most of the participants had training before Hajj, and most agencies required specific courses before working in Hajj. Therefore, this indicates good medical preparation. However, the course that was taken by most EMS providers was BLS, which is a higher percentage in comparison with a previous article (44%).[12] This course provides only basic interventions when approaching a patient. Subsequently, most of the EMS providers will provide only basic care even if the patient's condition was critical.

Mass gathering events are always straining the host's resources. Therefore, planning is very important before hosting an event. The study's results showed that most of the participants claimed that they have had enough resources during Hajj. Moreover, one of the resources is medications, which have an important role in treat and release. Paramedics who have the authority to administer medications in their guidelines can use medication on the scene to treat patients and decrease transportations to local hospitals. However, the number of paramedic was very minimal compared to technicians who do not have the authority to administer medications. Therefore, the treat and release plan (on-site treatment) was not efficiently functional. Whereas Feldman et al. had an effective treat and release plan, due to using medications and decreased transport to hospitals that reached 1.2%.[13]

Wearing full personal protective equipment and decontaminating the ambulance after transferring every patient is crucial for the safety of the healthcare providers and their surroundings. These two aspects can be affected due to the high demand of patients during Hajj. In our study, full personal protective equipment was confined to only wearing masks and gloves when EMS providers encounter patients. Regarding decontamination of the ambulance, it has not been assessed visually. However, only through providers' perspective in the survey where they claimed they decontaminate the ambulance after every use.

One of the important aspects of on-site treatment is definitive care on closed roads. Almost half of the providers chose to transport critical patients to the nearest facility with limited medical care. This is an indication that on-site treatment is not efficiently applied. On the other hand, the rest chose to treat on-site, which is a low rate compared to a previous study that had a successful implementation of on-site treatment (96%).[14]

Since Hajj demands long working hours, many emergency providers had to work more than 12 h per shift to cover the demand. Busy shift and lack of manpower were the main reasons for the overtime shifts. Which will result in burnout and a decrease in efficiency.[15] Also, our findings include closed roads and poor coordination with other government agencies such as road security. Consequently, paramedics were not allowed to reach the patient by ambulance. Thus, the provided care was limited with no implementation of on-site treatment.

Finally, despite capturing the majority of prehospital providers during hajj, few limitations do exist. Our data was restricted to the Hajj period, which is <7 days. This made data collection was difficult since different shift times made some providers not available to fill the questionnaire. The sample size did not include other emergency medical providers from the Ministry of Health since their hospitals refused to participate. Moreover, the data reflects only the Hajj season 2019.


  Conclusions Top


This study offers important recommendations for improving the EMS system's preparedness during Hajj, which include more manpower coverage as well as improved providers' qualifications and level of training. Furthermore, this study provides a recommendation to change the scope of practice to treat and release in the majority of cases rather than unnecessarily transport to the hospital. This study urges the importance of collaboration between agencies to facilitate the EMS system. The successful planning strategies will provide the EMS system planners a blueprint for mass gathering preparedness.

Acknowledgment

This research was supported by King Abdullah International Medical Research Center. We would like to thank the data collectors Mr. Hani Alqarni and Mr. Bandar Alotaibi who devoted their time to help us during data collection. We would also like to show our gratitude to the National Guards hospital for providing the data collectors accommodation during Hajj days.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mass Gatherings. World Health Organization. World Health Organization; 2018. Available from: https://www.who.int/ihr/ith_and_mass_gatherings/mass_gatherings/en/. [Last accessed on 2019 Apr 20].  Back to cited text no. 1
    
2.
Al-Otaibi A. An Assessment of the Disaster Preparedness Knowledge of Emergency Medical Services Providers in Hajj of 2016. Electronic Theses and Dissertations. Paper 2993; 2018.  Back to cited text no. 2
    
3.
Limited to Actual Haj. General Authority for Statistics; 2019. Available from: https://www.stats.gov.sa/en/28. [Last accessed on 2019 Apr 20].  Back to cited text no. 3
    
4.
Feldman MJ, Lukins JL, Verbeek PR, Burgess RJ, Schwartz B. Use of treat-and-release medical directives for paramedics at a mass gathering. Prehosp Emerg Care 2005;9:213-7.  Back to cited text no. 4
    
5.
Lukins JL, Feldman MJ, Summers JA, Verbeek PR. A paramedic-staffed medical rehydration unit at a mass gathering. Prehosp Emerg Care 2004;8:411-6.  Back to cited text no. 5
    
6.
Ordway EC, Sarna N, DeGeorge LM, Baird AM, Reid MJ, Nable JV. EMS resource utilization at college campus mass gathering events. J Coll Emerg Med Serv 2018;1:24-30.  Back to cited text no. 6
    
7.
Paras E, Butler M, Maguire BF, Scarfone R. Emergency preparedness for a mass gathering: The 2015 papal visit to Philadelphia. Disaster Med Public Health Prep 2017;11:267-76.  Back to cited text no. 7
    
8.
Karampourian A, Ghomian Z, Khorasani-Zavareh D. Qualitative study of health system preparedness for traumatic incidents in a religious mass gathering. Injury 2019;50:1097-104.  Back to cited text no. 8
    
9.
Glick J, Rixe J, Spurkeland N, Brady J, Silvis M, Olympia RP. Medical and disaster preparedness of US marathons. Prehosp Disaster Med 2015;30:344-50.  Back to cited text no. 9
    
10.
Chapter 03: HEALTH. General Authority for Statistics; 2019. Available from: https://www.stats.gov.sa/en/1009. [Last accessed on 2021 Sep 15].  Back to cited text no. 10
    
11.
Alshammari TM, AlFehaid LS, AlFraih JK, Aljadhey HS. Health care professionals' awareness of, knowledge about and attitude to influenza vaccination. Vaccine 2014;32:5957-61.  Back to cited text no. 11
    
12.
Krul J, Sanou B, Swart EL, Girbes AR. Medical care at mass gatherings: Emergency medical services at large-scale rave events. Prehosp Disaster Med 2012;27:71-4.  Back to cited text no. 12
    
13.
Feldman MJ, Lukins JL, Verbeek RP, MacDonald RD, Burgess RJ, Schwartz B. Half-a-million strong: The emergency medical services response to a single-day, mass-gathering event. Prehosp Disaster Med 2004;19:287-96.  Back to cited text no. 13
    
14.
El Sayed M, Tamim H, Mann NC. Description of medication administration by emergency medical services during mass-casualty incidents in the United States. Prehosp Disaster Med 2016;31:141-9.  Back to cited text no. 14
    
15.
Kollek D, Editor. Disaster Preparedness for Health Care Facilities. 1st ed. House-USA: People's Medical Pub; 2013.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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