Discussion

A comprehensive analysis of emergency health problems and health care services provided in SCs were targeted in the present study. To the authors’ knowledge, this is the most extensive study investigating health care services provided in SCs and might contribute to future planning of health care services in SCs.

The majority of patients seeking health care in EMIUs of SCs were female, in consistence with previous mass-gathering reports. ^{Reference Hnatow and Gordon5‐Reference Moreno Millán, RaposoTriano and ÁlvarezLeiva15} Steffen, et al reported association between female gender and increased risk of injury/disease in mass gatherings. ^{Reference Steffen, Bouchama and Johansson16}

Previous mass-gathering reports demonstrated a wide distribution in patient age and increased sensitivity of young children and elderly people to injuries and medical conditions in mass-gathering events. ^{Reference Hnatow and Gordon5,Reference Grant, Nacca, Prince and Scott6,Reference Grange, Green and Downs8,Reference Steffen, Bouchama and Johansson16,Reference Pérez-Gómez, Ramos-Zúñiga and Gutiérrez-Padilla17} Similarly, the age of patients seeking health care in SCs exposed a wide distribution. On the other hand, the number of presenting patients aged between 18 and 65 was higher than children and elderly population, and median age of the patients was 28. Therefore, presentation of patients of all ages should be taken into account during arrangement of health care services in SCs and training of EMIU staff.

The PPRs in SCs were lower than PPRs reported in previous mass-gathering events. ^{Reference Grant, Nacca, Prince and Scott6,Reference Moreno Millán, RaposoTriano and ÁlvarezLeiva15,Reference Pérez-Gómez, Ramos-Zúñiga and Gutiérrez-Padilla17–Reference Anikeeva, Arbon and Zeitz24} The PPRs of only two SCs in the present study were within the range of previous reports and in proximity of lower limit (Table 1). The present study constituted the report with the lowest PPR associated with mass gatherings in the literature. ^{Reference Arbon, Bridgewater and Smith3,Reference Alquthami and Pines20,Reference Michael and Barbera22,Reference Anikeeva, Arbon and Zeitz24,Reference Milsten, Maguire, Bissell and Seaman25} Low PPR might also be related with relatively low daily number of patients in SCs. Nonetheless, mass gathering in SCs should be considered as mass gathering with the highest total attendance since it is repeated every single day in a year. Previous reports by Pietro and Emilio, et al suggest international congresses as the long-lasting mass-gathering event which lasted six months. ^{Reference Marino, Albergoni and Andreassi14,Reference Moreno Millán, RaposoTriano and ÁlvarezLeiva15} Daily patient numbers in both reports were higher than those in the present study. The SCs provided ideal common living space when compared with other multi-day mass-gathering events, and also were less dependent on factors such as weather, alcohol use, and crowd mood, which are related with the number of patients seeking health care. ^{Reference Arbon, Bridgewater and Smith3,Reference Locoh-Donou, Yang and Berry23} Air conditioners help the maintenance of a controlled indoor temperature, thus minimizing negative effects of heat and moisture. Other factors related with low numbers of patients and PPRs might include easy access to water, food and resting spaces, prohibition of alcoholic beverages in SCs, different time windows of each customer spent in SC, lack of a shared psychological mood with protest or violence content, and lack of groups of densely packed people in spite of high numbers of customers.

The number of patients who presented on working days was found to be higher than those who presented on holiday days. However, the number of patients per day on holidays was higher than the number of patients per day on working days. Similarly, previous mass-gathering reports revealed increased number of patients presented on holiday days than those on working days. ^{Reference Moreno Millán, RaposoTriano and ÁlvarezLeiva15,Reference Zeitz, Schneider, Jarrett and Zeitz26,Reference Ceyhan, Demir and Güler27} Increased daily number of customers on holiday days in SCs might be closely associated with increased number of patients.

Demographics about whether the patient was SC staff or visitor were not regularly recorded in patients admitted in EMIUs. The majority of the recorded ones consisted of SC staff, in consistence with previous mass-gathering reports. ^{Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference Dutch, Senini and Taylor11,Reference Moreno Millán, RaposoTriano and ÁlvarezLeiva15,Reference Zhang, Wang, Chen, Ma and Dai28} Non-acute treatments (health care services) such as injection of prescribed medications, wound dressing, and measurement of blood pressure or glucose were provided in EMIUs, which also served as workplace health units of SCs. This choice of staff might be related with a contract between SC administration and staff, which might be offering workplace health coverage for people working in SCs. Nevertheless, it was previously reported that health care services free of charge and prevention of time loss during hospital visits and return periods are the primary causes for seeking medical advice of SC staff in EMIUs. ^{Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference Michael and Barbera22}

The present study detected greater numbers of patients presenting with medical conditions than with traumatic conditions in SCs. Minor medical conditions and injuries were the most common presentations, in consistence with the literature. ^{Reference Arbon2,Reference Arbon, Bridgewater and Smith3,Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference Steffen, Bouchama and Johansson16,Reference Milsten, Seaman, Liu, Bissell and Maguire18-Reference Alquthami and Pines20,Reference Zeitz, Schneider, Jarrett and Zeitz26,Reference Krul, Sanou, Swart and Girbes29}

The most common causes of traumatic conditions were lacerations and abrasions. Arbon, et al declared laceration as the most common injury requiring urgent intervention. ^{Reference Arbon, Bridgewater and Smith3,Reference Sanders, Criss, Steckl, Meislin, Raife and Allen30} Injuries such as lacerations and falls were shown to be more frequent in outdoor events, concerts, or fairs. ^{Reference Arbon2,Reference Arbon, Bridgewater and Smith3,Reference Grant, Nacca, Prince and Scott6,Reference Grange, Green and Downs8,Reference Pakravan, West and Hodgkinson12} Although SCs have indoor setting with a flat surface, lacerations and falls were not uncommon. Causes of injuries were not recorded in the majority of the data used for the present study. The recorded ones determined falls and sharp object injuries as the most common causes of injuries. Accidental injuries in kitchens of SC restaurants were assumed to be solely recorded as lacerations. Furthermore, falls and injuries were mostly associated with the use of common areas such as escalators, lifts, automatic doors, or wet and slippery grounds. Headache was the most frequent cause of medical conditions in EMIUs, as reported in several mass-gathering reports. ^{Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference Pakravan, West and Hodgkinson12,Reference Milsten, Seaman, Liu, Bissell and Maguire18,Reference Alquthami and Pines20,Reference Zeitz, Schneider, Jarrett and Zeitz26,Reference Sanders, Criss, Steckl, Meislin, Raife and Allen30}

Mental health-related presentations (107 patients, 1.6%) were similar with the number of patients in large-scale rave events reported by Jan Krul. ^{Reference Krul, Sanou, Swart and Girbes29} Suicidal attempts were three of the mental health-related presentations, so it may be reasonable to provide psychological training to EMIU staff for psychiatric emergencies.

Cardiac arrest or sudden cardiac death is uncommon in mass-gathering events. ^{Reference Arbon2,Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference De Lorenzo19,Reference Alquthami and Pines20} No cardiac arrest or sudden cardiac death occurred in SCs, despite relatively much higher attendance. However, when delay in intervention occurs as reported in previous mass-gathering reports, it is possible that medical conditions seen in SCs including chest pain, asthma, shortness of breath, allergy, and falling down from height have the potential of a life-threatening scenario. ^{Reference Arbon, Bridgewater and Smith3,Reference Milsten, Seaman, Liu, Bissell and Maguire18–Reference Alquthami and Pines20,Reference Zeitz, Schneider, Jarrett and Zeitz26} Besides, health care providers in SCs should definitely be equipped with Advanced Life Support training and automatic external defibrillators niched. ^{Reference Steffen, Bouchama and Johansson16} Additionally, automatic external defibrillators should be placed in easily accessible locations in each SC.

The TTHR in the present study was significantly lower than TTHRs of previous mass-gathering reports. ^{Reference Arbon, Bridgewater and Smith3,Reference Grant, Nacca, Prince and Scott6,Reference De Lorenzo19,Reference Alquthami and Pines20,Reference Michael and Barbera22,Reference Zeitz, Schneider, Jarrett and Zeitz26} The majority of patients in SCs were treated in EMIUs. A small portion of patients were directed to hospitals on their own or via ambulance. Furthermore, previous mass-gathering event studies demonstrated that injuries and medical conditions encountered in mass gatherings mainly consisted of minor medical conditions or injuries and were treated in first aid units, which thus resulted in decreased transport of patients to hospitals. ^{Reference Arbon2,Reference Arbon, Bridgewater and Smith3,Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference Milsten, Seaman, Liu, Bissell and Maguire18-Reference Grange, Baumann and Vaezazizi21,Reference Zeitz, Schneider, Jarrett and Zeitz26}

The most common treatment and medication provided by EMIU staff were wound dressing (1,476 procedure, 41.8%) and pain killer and myorelaxants (859, 12.7%), in consistence with the literature. The treatments administered in SCs were not complex. ^{Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference Thierbach, Wolcke, Piepho, Maybauer and Huth10,Reference Pérez-Gómez, Ramos-Zúñiga and Gutiérrez-Padilla17,Reference Milsten, Seaman, Liu, Bissell and Maguire18,Reference Ceyhan, Demir and Güler27}

Medical and traumatic conditions encountered in SCs were adequately and appropriately treated, and if required, rapidly transported to hospital EDs by EMIU staff, not including physicians within the context of this study. Concurrently, previous mass-gathering reports revealed competence of non-physician health care providers in the setting of emergency medical conditions and triage. ^{Reference Varon, Fromm, Chanin, Filbin and Vutpakdi9,Reference De Lorenzo19,Reference Grange, Baumann and Vaezazizi21,Reference Sanders, Criss, Steckl, Meislin, Raife and Allen30–Reference Feldman, Lukins, Verbeek, Burgess and Schwartz32} However, regulations included some treatments for which paramedics or EMTs are not authorized. Yazawa, et al underlined the need for regulatory revision with regard to authorization of EMTs in treatment options other than epinephrine injection in cardiopulmonary arrest. ^{Reference Yazawa, Kamijo, Sakai, Ohashi and Owa33} If not, SCs should recruit physicians, and all patients requiring oral or parenteral medications should be referred to hospitals, which will result in time waste and labor loss.