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ORIGINAL ARTICLE

MEDICAL STANDBY: AN EXPERIENCE AT THE 4TH NATIONALYOUTH CAMPING AND MOTIVATION PROGRAM ORGANIZED BY

MAKSAK MALAYSIA

Mohd Idzwan Zakaria, Ridzuan Mohd Isa, Mohd Shaharudin Shah Che Hamzah, Noor Azleen Ayob

Department of Emergency Medicine,School of Medical Sciences, Universiti Sains Malaysia, Health Campus

16150 Kubang Kerian, Kelantan, Malaysia

*Department of Emergency Medicine, Hospital Universiti Kebangsaan Malaysia

Medical standby is the provision of emergency medical care and first aid forparticipants and/or spectators in a pre-planned event. This article describes theframework and the demographics of a medical standby at the 4th National YouthCamping and Motivation Program in Pasir Puteh, Kelantan from 30th July untilthe 3rd August 2004. The framework of the medical team is described based on thework process of any medical stand by. A medical encounter form was created forthe medical standby defining the type of case seen (medical or trauma), name, age,race and diagnosis of the patient. We concluded that interagency collaborationduring the initial planning and during the event itself is needed to ensure the smoothrunning of the medical standby. Most of the medical encounters were minor illnesseswhich are similar to previous studies and there was no case transferred to thehospital during that period.

Key words : Medical standby, pre-hospital care

Introduction

Medical standby is a branch of pre-hospitalcare medicine. As emergency physician we areexpected to be an “emergency planner” for any massgathering event (2). Medical standby is the provisionof emergency medical care and first aid forparticipants and/or spectators in a pre-planned event(5). By definition, a mass gathering event is a pre-planned event, involved a gathering of many people(usually 1,000 or more) and confined to a single site(8). Being a teaching hospital, Hospital UniversitiSains Malaysia (HUSM) is seldom called to providemedical coverage to mass gathering event. We werevery lucky in August 2004 when the Department ofEmergency Medicine Hospital Universiti SainsMalaysia was invited by the Civil Servants Sportsand Welfare Organisation or Majlis Kebajikan danSukan Anggota-anggota Kerajaan (MAKSAK) fromthe very beginning to provide medical coverage for

the 4th National Youth Camping and MotivationProgram held in Taman Rehlah, Pantai BisikanBayu, Semarak, Pasir Puteh, Kelantan. Although thisevent didn’t fulfill the criteria for a mass gatheringevent, it is still was a pre-planned event involving alarge number of participants (165 participants and52 teachers and trainers) and confined to a singlesite. This was a good opportunity for the emergencymedicine residents to understand and practice theprincipals of medical standby.

The 4th National Youth Camping andMotivation Program was held from 30th July untilthe 3rd August 2004 in Taman Rehlah, Pasir Puteh,Kelantan. It was an annual event held by the CivilServants Sports and Welfare Organisation or MajlisKebajikan dan Sukan Anggota-anggota Kerajaan(MAKSAK). It was a national event where by 165students between the age of 15 to 16 year olds fromall over Malaysia gatherered in Taman Rehlah, atraining and recreational center at the shores of Tok

Submitted-20-2-2004, Accepted-20-12-05

Malaysian Journal of Medical Sciences, Vol. 13, No. 1, January 2006 (43-51)

44

Bali beach about 20 kilometers from the town ofPasir Puteh. These students were all children of themembers of the MAKSAK. It involved indoors andoutdoor programs. Indoor programs were restrictedin the classrooms and the outdoor programs involvedorienteering, abseiling, flying fox and kayaking.Such programs promote unity and team spiritamongst the participants. This article describes theframework and the demographics of a medicalstandby at the 4th National Youth Camping andMotivation Program in Taman Rehlah, Pasir Puteh,Kelantan.

Methods

The 165 participants of the program wereinvolved in outdoor activities like abseiling, flyingfox and kayaking and classroom activities in TamanRehlah and orienteering at Praksi Hill which was5km from Taman Rehlah. The medical team fromHUSM consists of an emergency medicine registrar,1 staff nurse, 1 medical assistant, 1 attendant and 1driver. Medical care was provided for 165participants of the program and 52 teachers andtrainers.

Mohd Idzwan Zakaria, Ridzuan Mohd Isa et. al

Table 1: Levels of medical coverage (5)Level Medical coverage Types of sports

activitiesMedical team

I Activities or sportsevents without anyrisk

Security officers arepresent around thespectators duringthe activities orsport events

Medical team fromthe nongovermmentalagencies examplethe St. John’sambulance or theMalaysian RedCross Societyequipped with firstaid kit

Grade B ambulance

II Activities or sportsevents without any risk of serious injuryto participants orspectators

Youth gatherings,small golfgatherings, trackand field events, andworkshops

i. medical assistants/ staff nurseii. health attendantiii. ambulance driver

Grade B ambulanceIII Activities or sports

events with bodycontacts. Moderaterisk

Boxing, karate-do,silat tournament,judo, soccer andmotor rally

i. medical officerii. medical assistants/ staff nurseiii. health attendantiv. ambulance driver

Grade A ambulanceIV Presence of VIP for

examples the RoyalHighness, Sultansetc., any hifh riskactivities or sportevents with a largenumber ofparticipants

International sportevents

i. emergency physicianii. medical officer medical assistants/ staff nurseiii. health attendantiv. ambulance driver

Grade A ambulance

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The framework of the medical team wasdescribed based on the work process of any medicalstand by. They were divided into job description,risk analysis, resource matrix, contingency planningand table-top exercise.

Job descriptionJob description was done in order to justify

the team and equipments sent to cover the event.This was formulated based on the Ministry of HealthMalaysia Guidelines for Medical Stand by (5). Basedon table 1 below, we have classified it into a LevelIV as it involves high risk sport events likeorienteering, abseiling, flying fox and kayaking.

Risk/situational analysisIn this program, the participants were all fit

16 year old students. There were no VIP presentduring the event. There was also no alcohol or illicitdrugs involved in the event. The event was held inTaman Rehlah, training and recreational center atthe shores of Tok Bali beach about 20 kilometersfrom the town of Pasir Puteh. Figure 1 below showsthe distance between Taman Rehlah and theresponding hospitals. The nearest hospital wasHospital Pasir Puteh which was 20km but the nearesthealth clinic was Cherang Ruku Clinic which wasabout 2.5km away. As Pasir Puteh hospital was thenearest hospital, suggested that triage green casesrequiring hospital admission could be transferred toPasir Puteh Hospital but triage yellow and red shouldbe transferred to Hospital Universiti Sains Malaysia(HUSM) after stabilization in the medical post. This

is due to the lack of facilities available in Pasir PutehHospital. Patient transfer would be done usingambulance as the roads were easily accessible andduring our on site survey we noted that it took 20minutes by ambulance to reach Pasir Puteh Hospitaland 45 minutes to HUSM from Taman Rehlah.Although it takes > 20 minutes by ground ambulanceto HUSM but the availability of ground ambulanceand easy patient access, we decided to utilize theground ambulance. All patients arrived to thehospital from the program would be “fast-tracked”in the emergency department.

Figure 2 shows the proposed medical postwhich had been moved to the front of the main hall.This was because of easy accessibility of ambulanceto the medical post and nearer to the sites where theabseiling, flying fox activities and kayaking weredone. We had also stationed another ambulance witha mobile team from the Civil Defense beside thelake to standby during kayaking activity. During thekayaking activity, the Civil Defense team had alsoprovided a boat manned by life-savers to monitorthe event. Figure 2 also showed the ambulanceevacuation route. During the orienteering programat the Praksi Hill, we had provided a four by fourvehicle with 1 HUSM‘s medical assistant and 2 CivilDefense personals during the activity. Site surveyshad to be done prior to the events in order to comeup with the proposed coverage. Site surveys had tobe done with approval of the event organizer(MAKSAK) and site organizer. The new site of ourmedical post was organized after careful discussionwith MAKSAK and site organizer.

MEDICAL STANDBY: AN EXPERIENCE AT THE 4TH NATIONAL YOUTH CAMPING AND MOTIVATION PROGRAM ORGANIZED BY MAKSAK MALAYSIA

Figure 1: Situational analysis of Taman Rehlah

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Figure 3 shows the schematic diagram of themedical post. It in a safe area with easy access toambulance traffic (4). Negotiations with theorganizer need to be done in order to supply theelectricity and water for the medical post. A gazebowas put up as a medical post. Gazebo was notappropriate for this event as it can be blown awayby the wind if not anchored properly to the ground.Our contingency plan if such incident occurs was tomove our medical post to the verandah in front ofthe main hall.

Walk-in care was provided at the medical poststaffed by an emergency medicine registrar, a staffnurse and an attendant equipped with Advanced LifeSupport (ALS) care equipments from 8 am until4.45pm by the HUSM team. A mobile medical teamwas provided during kayaking by the Civil Defense.2 ambulances were utilized during the event, a gradeA ambulance from HUSM staffed by a driver withemergency medical dispatcher certificate and a gradeB ambulance from the Civil Defense. They alsoprovided a four by four vehicle for this event. Thegrade A ambulance was stationed at the medical postand the Malaysian Civil Defence’s grade B

ambulance was stationed beside the lake. The fourby four vehicle was stationed at the medical checkpoint at the base of Praksi Hill staffed by a medicalassistant from HUSM and two Malaysian CivilDefence personals.

The medical post received walk-in patientsas well as cases from the mobile teams. A triage areawas set up staffed by the staff nurse. Medical postcapabilities included ALS, intravenous rehydration,simple cooling measures, simple suturing and woundcare, splinting, dispensing of medications (includinganalgesics, antacids, antibiotics, antidiarrheal agents,antiemetics, antihistamines, antiinflammatories andbronchodilators). Any transfer from the medical postto Pasir Puteh Hospital or HUSM must receiveconsent from the “Supervisor Medical Team” at theoperation center. Triage green cases requiringlaboratory work, radiographs and rehydration couldbe managed in Hospital Pasir Puteh but triage yellowand red had to be transferred to HUSM afterstabilization at the medical post.

A medical encounter form was created for themedical standby defining the type of case seen(medical or trauma), name, age, race and diagnosis

Mohd Idzwan Zakaria, Ridzuan Mohd Isa et. al

Figure 2: Diagram showing the proposed medical post and the new medical post and ambulanceparking points in Taman Rehlah.

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of the patient. The treatment given was also statedin the form. Patient care data then transferred tocomputer. The demographic data were evaluatedfrom the medical encounter form using MicrosoftExcel.

Resource matrixResource matrix consisted of manpower and

specialty, equipment, communication, transport andother agencies

The manpower, specialties and equipmentsneeded are described above. The medical team washeaded by a “supervisor medical team” which iscontactable at all times. He/she would supervise theteam and act as the team leader. An emergencyphysician on call on that day would stand by in thehospital and would provide clinical advice to theteam if needed. Standard Operating Procedures(SOP) were written for the medical post, operationroom and hospital management. Communicationbetween the event areas including the site oforienteering which was Praksi Hill and TamanRehlah were tested using walkie-talkie and handphones. Interagency support during the event wasextraordinary amongst the HUSM, Civil Defense,Pasir Puteh’s Hospital, Fire and Rescue team, police,MAKSAK organizer team and Taman Rehlah’steam.

Contingency planningContingency plans were drawn up before the

medical standby in relation to evacuation routes,manpower, equipments, transport and inter-agenciescooperation.

Table-top exerciseThese exercises were done prior to the medial

standby. It involved “scenario mapping”, inter-agencies cooperation and work process accordingthe standard operating procedures.

Results

Over the 4 days of the event, 14 patients wereseen at the medical post, an average of 3.5 patientsper day and a daily frequency of 1.6 encounters per100 participants, teachers and trainers. 13 patients(93% of the encounters) were medical cases and only1 patient was a trauma case who had soft tissueinjury. All patients were triage green by the staffnurse and all patients were being seen by anemergency medicine registrar. Figure 4 below showsthe percentage of patients seen at the medical postduring the program. The pie chart shows an increaseof patients seen as the program progresses.

Table 2 above shows the distribution ofmedical encounters during the program. None of thepatients require transfer to hospital and none of them

Figure 3: Medical post schematic diagram

MEDICAL STANDBY: AN EXPERIENCE AT THE 4TH NATIONAL YOUTH CAMPING AND MOTIVATION PROGRAM ORGANIZED BY MAKSAK MALAYSIA

48

require intravenous fluid therapy. However, 2patients were given intravenous injection, one foran allergic reaction and the other for vomiting fromacute gastroenteritis. The patient with acuteexacerbation of bronchial asthma was givennebulised salbutamol at the medical post anddischarged with oral prednisolone. The rest of thepatients seen at the medical post were seen anddischarged with oral medications.

Discussion

Medical standby being a branch of pre-hospital care requires careful organization byemergency physician. Such experience is vital foremergency medicine residents who is currentlyundergoing the master’s program in Universiti SainsMalaysia (1). Understanding the principal of eventmedicine and applying it’s importance for thesuccess of the event and to prevent any lawsuitsbased on bad outcomes in crowd situations that wereclaimed to have been “insufficiently planned” (4).

Emergency physicians and emergencymedical residents had to understand the goals of amedical standby. This was to ensure the fast, safe,smooth and stealthy treatment and evacuation of apatient.

Rapid access to patient was vital to ensurefast treatment for the patient. However, this accesshas to be subtle in order not to create panic and attractattention of the media which will be detrimental tothe patient and the organizer of the event. This wasan up most important if the patient is a (VeryImportant Person) VIP or if the event is a national

or international one.Evacuation to appropriate hospital is vital in

medical standby (5). Hospital selection should bebased on patient needs and hospital capability (6).As HUSM is the regional referral center for the eastcoast of Malaysia, providing neurosurgical,cardiothoracic, cardiology etc services, it is onlyappropriate that the responding hospital for this eventis HUSM.

An operation center has to be created duringthe medical standby. This center acts as a“coordination center” between the medical team andthe receiving hospital. The operation center has tobe able to communicate with the medical team at allparts of the event venue.

The planning of the standby is the key to asuccessful medical coverage. The emergencyplanner should formally meet with the organizer toascertain what is expected of the emergency medicalgroup and to learn of his or her understanding of thelevel of medical care expected (4). This jobdescription allows the emergency planner theappropriate level of equipment and staff for theevent. Special considerations which may affect therecommended medical resources are night vs.daytime event, number of active participants, alcoholavailability and anticipated use, demographics ofcrowd, number of attendees, location of event/multiple locations, weather/time of year, length ofevent and problems encountered with event in thepast.

Obtaining the equipment was another issuein medical standby. The emergency planner mightbe able to get donations (or loans) of equipment andsupplies from hospitals and medical/drug companies

Figure 4: Percentage of patients seen at medical post according to date

Mohd Idzwan Zakaria, Ridzuan Mohd Isa et. al

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(4). The number and types of attendees could bemade known from the organizer or if it was an eventthat requires ticket sales, then the number sold wouldgive us the information.

Risk analysis and situational analysis requiredcalculated analysis of various factors in the event.The duration of the event was important to determinethe number of staff needed at the medical post. Riskanalysis of the event site was important in order toaccess the flow of people to your medical post, theease of access of ambulances to the medical postand evacuation and potential hazards of the outdoorevents. In previous study on mass gatherings, it wasconcluded that the medical support needed wasbased on event size (7, 8). But the choice of medicalsupport for this event were based on nature of theevent, environmental conditions and accessibility ofpermanent medical facilities which were includedin our risk and situational analysis (9). For example,the risk analysis of the outdoor events were relatedto the potential trauma and heat related illness duringorienteering, abseiling and flying fox activities andsubmersion during kayaking. In view of thesepotential injuries, our emergency medicine registrarson duty were all ACLS/ATLS trained, the medicalpost was equipped with resuscitation drugs and ourambulance was upgraded to grade A ambulance.

The medical aid stations at an event should

be accessible within 5 minute walk and should beclearly marked so that all event personnel knowabout the location of the aid stations. It should be ina safe area and have easy access to the ambulance.We feel that gazebo was not the right choice for amedical post beside the beach. But due to financialconstraint we had to make do with the gazebo.Gazebo was not appropriate for this event as it canbe blown away by the wind if not anchored properlyto the ground. In view of these basic principals, wehave stationed the medical post in front of the mainhall where the main event was held. We had alsoput 1 mobile team near the kayaking and orienteeringprograms respectively. Communication was vital atthe medical post. The physician in charged on-siteshould be able to communicate with the site-organizer personnel, fire and rescue team, police,supervisor of the medical team, medical personnelon-site and operation center.

The overall medical commander was thesupervisor medical team (SMT) which could bestationed on-site or at the hospital and contactableat all times. The emergency medicine registrar onduty on that day would report to him/her of anymedical incidents. The chain of command waswritten clearly in our “standard operatingprocedures” and agreed upon by the EmergencyDepartment HUSM. The SMT was responsible for

Table 2: Medical encounters during the event

MEDICAL STANDBY: AN EXPERIENCE AT THE 4TH NATIONAL YOUTH CAMPING AND MOTIVATION PROGRAM ORGANIZED BY MAKSAK MALAYSIA

Diagnosis

Acute gastroenteritis

Allergic reaction

Dizziness

Insect bite

Soft tissue injury

Upper respiratory tract infection

Gastritis

Dysmenorrhea

Vasovagal attack

Acute exacerbation bronchial asthma

Total

3

2

2

1

1

1

1

1

1

1

%

21.4

14.3

14.3

7.1

7.1

7.1

7.1

7.1

7.1

7.1

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the medical coverage of the event. He/she was alsoresponsible to resolve any unforeseen problemsduring the event. Transfer of patients to the hospitalhad to be noted to the SMT. He/she was responsiblefor communicating with the emergency physicianon call and receiving specialty team about the case.

Interagency support during the event wasextraordinary amongst the HUSM, the CivilDefense, Pasir Puteh’s Hospital, Fire and Rescueteam, police, MAKSAK organizer team and TamanRehlah’s team. This was achieved by buildingrapport during meetings and respecting the otherteams’ expertise. We were very grateful toMAKSAK for having confidence in us, calling usto every important meetings and providing with anyalterations with the event schedule. This splendidinteragency support was vital in order to maintainsmoothness in running the medical standby.

The patient would be “fast-track” once arrivedat the emergency department meaning patient wouldbe seen immediately on arrival, treated by theemergency department team and the respectivespecialty team/s before admission to the ward. The“fast-track” system was good for the patientsbecause they are cared for quickly and efficientlywithout spending hours in the waiting area. The“fast-track” system was implemented in medicalstandby in order to provide fast treatment for thedelegates and participants of the event. Moreover,the patient had already been seen at the medical posthence should not be burden by waiting too long atthe waiting area.

Patient encounter form was made for medicallegal purposes and data collection for futureplanning. Ideally forms could be made with NCR(no carbon required) form so that medical personnelcould send a copy with the patient if he or she goesto the hospital as well as to keep a copy at the aidstation but due to financial constraint we were unableto do one. In our medical standby, the daily rate ofpatients seen was 1.6 patients per 100 participantsor 16 patients per 1000 participants. Reported patientpresentation rates (patient presenting per 1,000spectator) have varied significantly with valuesranging from 0.14 to 90.0, though most reportedevents have ranged between 0.5 and 2.0. The rangeof patient presentation rate reported reflectssignificant variations in factors such as weather,event type, and data collection and reporting formats(10). All of our medical encounters were minorillnesses like acute gastroenteritis (21.4%), dizziness

(14.3%), allergic reaction (14.3%), insect bite(7.1%), soft tissue injury (7.1%), upper respiratoryinfection (7.1%), gastritis (7.1%), dysmenorrhoea(7.1%), vasovagal attack (7.1%) and mildexacerbation of bronchial asthma (7.1%) which didnot require transfer to the hospital. This demographicfeature is similar to previous study done by DeLorenzo which states that respiratory illnesses,minor injuries, heat-related injuries, and minorproblems (headache, blisters, sunburn) comprise75% of patient presentations. However in this event,only 7.1% of the patient presentations were softtissue injuries although most of the activities wereoutdoors. This was probably due to the extensivesafety precautions and monitoring taken during theevents.

There was an increase of patients as the eventsprogress from 21% on day 1 to 50% of the totalmedical encounters on day 2. This was probably dueto the physical and mental fatigue of the participantsas the events progress. We were unable to correlatewith the humidity and environmental temperaturedue to inability of data in the medical encounterform. This data should be available in the medicalencounter form in future for a more comprehensivedata collection and correlation. None of the medicalencounter required transfer to the hospital in thisevent. This could be due to many probabilities suchas small sample size, strict supervision and controlof the outdoor and indoor activities and theenvironment was conducive for outdoor activities.A more extensive study had to be done to justify theteam and equipments ventured during a medicalstandby.

Conclusion

Medical standby requires careful planning andorganization prior to the event. Emergencyphysicians who were trained in disaster and massgathering medicine were expected to act as theemergency planner. Interagency collaboration duringthe initial planning and during the event itself isneeded to ensure the smooth running of thecontingency plans during the medical standby.Most of the medical encounters were minor illnesseswhich is similar to previous studies. Moreover therewas no case transferred to the hospital. A moreextensive study has to be done on various massgathering to justify the team and equipmentsventured during a medical standby.

Mohd Idzwan Zakaria, Ridzuan Mohd Isa et. al

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Correspondence :

Dr. Mohd Idzwan Bin Zakaria (MB Bch BAOIreland) MMed Emergency Medicine (USM)Department of Emergency Medicine,School of Medical Sciences,Universiti Sains Malaysia, Health Campus,16150 Kubang Kerian, Kelantan, MalaysiaTel: 09-7663244 Fax: 09-7653370e-mail: idzwan@kck.usm.my

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MEDICAL STANDBY: AN EXPERIENCE AT THE 4TH NATIONAL YOUTH CAMPING AND MOTIVATION PROGRAM ORGANIZED BY MAKSAK MALAYSIA