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Raves and Saves: Massive Music Festivals Call for Advanced Emergency Care

Although the headlines are increasing in frequency, they are still alarming: “Fans Hospitalized in Latest Dance Music Setback.” “Overdoses of ‘Molly’ Led to Electric Zoo Deaths.” “Dangerous Dance Music?” “EDM Concerts Plagued by Security, Health issues.”

Electronic dance music (EDM) festivals are a burgeoning business: According to an article in The New York Times, EDM is a $6.2 billion industry, which includes recordings, live events and corporate sponsorships [1].

The number of festivals and attendees is at an all-time high — despite a series of well-publicized hospitalizations and deaths. Two attendees of Electric Zoo 2013, a major EDM festival in New York City held over Labor Day weekend last year, died after ingesting toxic stimulants. This prompted the cancellation of the third day of the festival [2]. In addition, as many as 15 others, were hospitalized in critical condition [3].

In March, six festival goers at the Future Music Festival Asia in Malaysia died from drug-related incidents, and three more critically hospitalized, leading to the cancellation of the third day of that festival as well. On a recent weekend in June, the Electric Daisy Carnival drew 400,000 people to the Las Vegas Motor Speedway, and three deaths have been linked to the festival [4].

New York City’s medical examiner attributed the two deaths at Electric Zoo 2013 to fatal ingestions of MDMA and methylone. MDMA, marketed as “Molly” in powder form and “Ecstasy” in pill form, is now undergoing resurgence in popularity that is inextricably entwined with the rise of EDMs. Methylone, a close structural analog of MDMA and a common component of bath salts, is also a frequent adulterant of Molly/Ecstasy.

Para-methoxyamphetamine or PMA, sold on the street as “Dr. Death,” is a relative newcomer at EDM events but also been attributed to several deaths in the U.K. and U.S. According to Poison Review, it is more potent than MDMA with a longer duration of action, yet its distinguishing characteristic is a longer time of onset; attendees ingest it prior to entering evading festival security measures. Its delayed onset leads to larger ingestions and greater toxicity [d].

Illicit substances sold at festivals are often adulterated and cannot be reliably identified by appearance or patient report alone. MDMA, methylone and PMA all present with variations of sympathomimetic toxidromes familiar to emergency physicians and EMS, including hallucinations, hyperthermia, seizures, coma, hypoglycemia and hyper- or hyponatremia, hypertension (or hypotension once monoamines are depleted), supraventricular and ventricular arrythmias.

These and other deaths have exposed the widespread drug use at EDM festivals. They have also thrown a spotlight on a relatively new field of medical study: Mass Gathering Medicine (MGM).

About MGM

Although the study of MGM is still in its embryonic stages, the growing number of casualties resulting from EDM events makes this an important topic for emergency physicians, perhaps even spawning an alternative career path or moonlight gig: Event medical director.

While prospective data are scarce, there has been a fair amount of scientific analysis in the field of MGM. An inherent difficulty with MGM is the lack of structured and formal guidelines. In fact, there is no uniformly recognized definition for what constitutes a “mass gathering.” Most experts agree that an event with more than 1,000 attendees should be considered a mass gathering. The World Health Organization defines mass gathering as “the number of people attending is sufficient to strain the planning and response resources of the community, state, or nation hosting the event”. MGM medical preparedness recognizes that patient presentation rates (PPR) at mass gatherings is higher than that of the general populace of similar size (Turis and Lund 2012).

Few validated models exist to predict the medical resources necessary for an event of given size and type since they apply to specific mass events, not events in general. (Basdere et al. 2014); (Smith et al 2012). The vast majority of MGM literature is observational or case-controlled (Arbon et. al 2014). Nevertheless, while the study of MGM is still in its infancy, analysis of several mass gatherings allows us to draw some conclusions regarding the demand for medical care and successful management strategies.

Multiple Medical Problems at Mass Gatherings

Medical demand at a mass gathering reflects the specific characteristics of that event (e.g. outdoor events produce more environmentally related injuries such as lacerations, sunburns and heat exhaustion while events attracting young people such as rock shows produce more alcohol and drug abuse-related complaints) (Arbon 2007). Temperature and relative humidity are directly correlated with a significantly higher PPR than would otherwise be expected (Soomaroo and Murray 2010). Shortening the length of day events decreases sun exposure and watering down grounds reduces the ground temperature, which lessens the PPR. Access to free drinking water has also been suggested, and in some cases mandatory, to reduce heat-related complaints and the PPR. The deceased revenue to promoters is offset by the positive publicity and decreased medical usage rate (MUR). However, large ingestions of water in MDMA users can cause hypervolemic hyponatremia given the drug’s effects in increasing ADH secretion and intravascular volume.

The most common mass gathering complaints are lacerations and other musculoskeletal injuries, heat-related injuries, and an assortment of medical complaints such as asthma (3% of complaints in one Australian study (Arbon 2007); most of these are minor and do not require transport to hospitals (Alquthami et. al 2014). Critical illnesses at EDM events are often caused by hyperthermia, hypoglycemia, seizures, ventricular arrhythmias and resultant anoxia. We suggest a ‘Resuscitation Bay’ in each medical tent with cardiac monitors, cold fluids, advanced airway equipment including supraglottic airway devices and readily accessible pharmacology for critical patients. Regardless of the ambient or ground temperature, we recommend at least one large cooling bath and a large amount of bagged ice for the severely hyperthermic sympthathomimetic toxidrome patient. Benzodiazepines, first line treatment for the agitation and seizures that can result from amphetamine toxicity and glucose in either oral or intravenous form should be on standby. Paralysis via RSI should be conducted for hyperthermic patients with autonomic instability to prevent further derangements in thermoregulation. Rocuronium, a non-depolarizing neuromuscular blocker is the agent of choice as succinylcholine should be avoided since the risk of rhabdomyolysis is considerable. Additionally, dantrolene is a controversial topic in MGM offering potential benefit as adjunctive therapy in the treatment of hyperthermia secondary to sympathomimetic toxicity (Grunau et. al 2010). We suggest its use in severely hyperthermic patients.

Game Plan for EDM Festivals

It’s clear to us that emergency physicians should be on-site at these festivals to deal with the ever-increasing medical problems. The presence of physicians on-site at mass gatherings decreases the transfer to hospital rate (TTHR) (Grange et. al 2003). Given the multiple variables and complexity involved in predicting medical demand and the MUR for mass gatherings, a needs analysis and allocation of resources should be based on data from the same or similar events within the past year. Here’s how to game plan prior to the event:

• Conduct tabletop exercises, designed to familiarize ED staff, EMS providers, and festival promoters with the size and nature of the gathering, likely chief complaints.
• Develop incident action plans (IAPs) (Michael and Barbera 1997) IAPs should be tailored to the location (in- door/outdoor), duration (length of event), nature (mobile vs. stationary crowd), spectator profile, size, and approximate heat index of the event.
• Brief prehospital providers and logistics personnel on the specialty hospitals and limitations of nearby resources. Promoters frequently hire private security companies who have little knowledge about local municipal policies and protocols.
• Conduct full-scale drills (if time and budget allow) to enhance coordination and collaboration of law enforcement, fire prevention, EMS provid- ers, and festival security, who often are the personnel identifying patients at festivals.
Electronic dance music festivals commonly have active and mobile, rather than seated, participants, two factors that increase PPR. Additionally they often take place during the summer and there is a high incidence of polysubstance use suggesting a medical demand profile that is unique from other mass gatherings. Due to the high rate of drug usage and hot weather, we can expect a number of critical illnesses at EDM events, as evidenced by our experiences and recent headlines. To that end, we suggest several strategies to reduce the PPR, increase safety and improve medical outcomes at EDM festivals:

1. Develop multiple access points for EMS to allow for a considerable decrease in time to medical intervention and transport (Soomaroo and Murray 2012). Ingress/egress points at festivals are tightly controlled given the large quantity of illicit substances brought to these events; however there must be reliable and quick entry points for EMS to gain access to patients. Pathways that are hindered with vehicles or attendees can slow EMS’ response and transport time leading to critical delays. Additionally, pathways for emergency vehicles around the festival where patients can be speedily transported to medical tents must be maintained free of obstacles and people. While it is logistically difficult to maintain open pathways solely for EMS use, ideal venues should be chosen and repeatedly used for high-risk events. For example, Randall’s Island in New York City is a frequent site for mass gatherings for good reason. There are four trauma centers in three boroughs and four additional tertiary care centers within a ten-minute transport time from the venue. A peripheral access road encircles the venue which is off-limits to attendees yet provides quick access points for EMS to evaluate patients.
2. Drug amnesty bins traditionally have minimal compliance but can be deployed with minimal strain on resources and if positioned properly, have demonstrated success in some cases (Mysteryland 2014).
3. Stringent security measures at every ingress reduce the flow of illicit substances in a mass gathering venue. Drug sniffing dogs can identify toxins hidden in body orifices, a common way that users or sellers gain entry with drugs. Each attendee should be thoroughly frisked upon arrival to identify and deter drug entry into a festival. Admittedly, it is difficult to thoroughly search 45,000 festival goers upon entering a venue given the time and space restrictions placed on security companies. However, in our experience, although difficult to study, there is a direct correlation between security effectiveness and the PPR.
4. Clearly identify medical personnel to search the crowd for people who appear obtunded or in distress and transport them back to medical tents. A contributing problem to the mortality at EDM festivals, evidenced by Electric Zoo 2013, is that attendees in distress are often overlooked by the reveling crowd and hidden to the medical providers seeking to help them.
5. Develop pre-event education on the location and safety of medical tents as “amnesty zones,” which also will help reduce the fear that may prevent critically ill patients from seeking help. A young man at Ultra 2014 in Miami who was feeling ill was removed from the festival by his friends and taken to his car to ‘sober up,’ only to be found dead hours later [e].
6. Consider organizations such as DanceSafe, Bunk Police, or EZ Test which provide cheap and effective drug testing kits at their events, given the high frequency of drug adulteration. However, these tests are limited in their efficacy as PMA and other structurally similar compounds can pass as unadulterated MDMA, lulling users into a false sense of security and potentially leading to lethal ingestions.

The bottom line: Illicit substances will continue to enter venues and will continue to cause significant morbidity unless emergency physicians, whether called festival medical directors or not, adequately prepare for the symptomatology common in MGM. We must be prepared to treat the common toxidromes of PMA, MDMA, methylone, and methamphetamine as well the myriad other chief complaints seen at mass gatherings. raves-gear-main

TOP TEN TAKEAWAYS ON MASS GATHERING MEDICINE 1. Drugs are often adulterated. Do not rely on the appearance of the drug or the report of the patient to make a determination on treatment.
2. MDMA (Molly, Ecstasy), methylone and PMA all present with variations of sympathomimetic toxidromes. Overdoses may lead to severe hyperthermia
3. Given higher rates of critical illness/drug toxicity at EDM events, medical tents must be better equipped/staffed than other mass gatherings. Make sure there are readily available cooling baths, bagged iced, ‘resuscitation bay’ setup and rocuronium enabled RSI.
4. Avoid succinylcholine in RSI.
5. Use active and passive cooling to treat hyperthermia and consider dantrolene as adjunctive therapy.
6. Develop Incident Action Plans to enhance medical care.
7. Develop tabletop exercises prior to the event to improve collaboration and ensure better patient outcomes.
8. Easily recognizable medical personnel should be “crowd searchers” looking for critically ill patients
9. Create amnesty bins and amnesty zones, which create better management of patients.
10. Develop pre-event education on location/appearance of medical tents.

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