Discussion

Mass gathering medicine is performed in a unique and demanding environment, and the majority of BUEMS EMTs initially felt uncomfortable providing care at Agganis Arena (see Table S1). ^{Reference Jaslow, Yancy and Milsten3} Since mass gathering medicine education is not mandatory during initial EMT coursework to obtain certification, the majority of BUEMS EMTs reported little or no formal training in LVEMS before working at the arena (see Table S3). ^{Reference Schwartz, Nafziger and Milsten7}

Agganis Arena has the capacity to host thousands of guests located between multi-level stadium-style seating and standing-room floors, so EMTs must understand how to efficiently and safely extricate patients (see Figure 1A). After the orientation, NA-EMTs had twice the knowledge of arena layout and increased equipment skills for difficult extrications (see Table 1).

Additional training regarding typical large-venue emergencies and protocols covered care and management of individual patients. This training significantly increased NA-EMT knowledge of LVEMS procedures, including managing the high volume of altered mental status and intoxicated patients (see Table 1). These skills are vital for MGE EMTs, as substance use is linked to nearly 96% of the people transported to the hospital from a large venue, with 50% using more than 1 illicit substance. ^{Reference Ruest, Stephan, Masiakos, Biddinger, Camargo and Kharasch9}

Representative of many MGE logistics, BUEMS EMTs must care for multiple simultaneous patients and decide which patients require transport for further care. ^{Reference Lund, Gutman and Turris6} Many of these are medically complex patients, with up to 48% requiring care beyond prehospital capabilities. ^{Reference Lund, Gutman and Turris6,Reference Martin-Gill, Brady and Barlotta10} Through the peer-mentorship program, NA-EMTs always had more experienced providers to guide their treatment decisions and thus teams reported increased confidence that each call would go smoothly (see Table 1).

The mentorship program was created to benefit NA-EMTs, but the results also showed an increase in overall EMS team dynamics (see Figure 1C). Team dynamics is especially important during MGEs, as the chaotic and loud environment can often make communication between providers extremely difficult. ^{Reference Jaslow, Yancy and Milsten3} One-on-one team pairing increased coordination of both patient care and EMS operations, which may have improved patient management decisions (see Figure 1C).

During the large-venue in-service, AE-EMTs who proctored the scenarios were able to use their own large-venue experiences to guide students through the skills (Supplementary Text 4A-C). Each scenario was simulated as a full, comprehensive patient encounter, including dispatch, initial contact, treatment, extrication, and transport. The curriculum covered MGE skills that are excluded from the National Standards for EMS Education, including the treatment of intoxicated minors, noncompliant refusals, and treat-and-release, which occur often in the large-venue environment. ^{Reference Yancy, Luk, Milsten and Nafziger5,Reference Samuels, Bock, Maull and Stoy8}

After the in-service, students reported increased confidence in triaging, providing appropriate care, and using equipment, all of which are regularly performed in the large-venue setting (see Figure 1C). ^{Reference Morimura, Mizobata and Sugita4,Reference Lund, Gutman and Turris6} BUEMS EMTs were also taught how to adapt communication skills to the large-venue setting, which is essential for coordinated emergency care (Supplementary Text 2). ^{Reference Jaslow, Yancy and Milsten3,Reference Yancy, Luk, Milsten and Nafziger5,Reference Lund, Gutman and Turris6} As a result, EMTs reported increased confidence regarding care decisions and increased teamwork (see Figure 1C).

Additionally, MGE providers are not given an exact address in a large venue but rather a generalized location of the patient, often within a dense crowd. ^{Reference Jaslow, Yancy and Milsten3} During the guided tour, EMTs were taught how to traverse this multi-level environment and reported a large benefit in navigating the layout (see Figure 1C).

This preliminary evaluation did yield many potential program benefits, but further research should also explore the program’s impact on specific aspects of patient care, including response times, correct and thorough treatment initiation, and adherence to large-venue protocols. A future study should also test the program efficacy with a new cohort of EMTs and during mass gathering events at another institution.