DÄ internationalArchive28-29/2011Patient Care at the 2010 Love Parade in Duisburg, Germany

Original article

Patient Care at the 2010 Love Parade in Duisburg, Germany

Clinical Experiences

Dtsch Arztebl Int 2011; 108(28-29): 483-9. DOI: 10.3238/arztebl.2011.0483

Ackermann, O; Lahm, A; Pfohl, M; Köther, B; Lian, T K; Kutzer, A; Weber, M; Marx, F; Vogel, T; Hax, P

Background: The mass panic at the Love Parade 2010 attracted a great deal of public attention in Germany and abroad. The goals of this paper are to summarize the available data on the injured persons and their treatment, and to assess the preparations that should be made for such an eventuality and the acute measures that should be taken if it occurs.

Methods: Patient data from the Duisburg hospitals were subjected to a structured statistical analysis, and all of the measures taken were assessed by qualified evaluators on the basis of questionnaires, a consensus conference, and individual interviews of the clinical coordinators.

Results: A total of 250 000 persons took part in the Love Parade; 5600 patient contacts occurred at first-aid posts and 473 patients (mean age, 25.5 years; male:female ratio, 1.4:1) were treated in 12 hospital emergency rooms, 41.7% were admitted to the hospital. Among the admitted patients, 73% stayed in the hospital for less than 24 hours, and 41% signed out against medical advice; 62.2% had a surgical diagnosis, 40.6% a medical one, and 8.0% a psychiatric one (some patients had more than one diagnosis). 47.6% of the surviving patients were classified as mildly injured, 47.8% as moderately injured, and 4.0% as severely injured. Most medical activity was concentrated in three areas: the treatment of drug abuse, the care of many mild and moderate injuries, and Shock Room diagnostic assessment of patients potentially harboring serious injuries. Hospitals were subject to the highest strain 2 to 3 hours after the mass panic, at which time they received up to 20 new patients per hour.

Conclusion: These data permit a detailed view of the medical care that was provided. In situations of this kind, the main problems can be dealt with through targeted and structured preparation and optimized emergency plans which consider both foreseeable and unforeseeable events. Priority must be given to rapid diagnostic assessment and clinical decision-making; the prerequisites for these are transparent institutional structures and clear assignments of responsibility.

LNSLNS

The Love Parade 2010 was a challenge for both the emergency services and the hospitals involved. The festival, which involved 250 000 participants from all continents of the world, was the scene of a mass panic in a narrow stretch of tunnel, leading to 21 dead and more than 400 injured. This corresponds to level 4 of the German Red Cross’s mass casualty incident severity scale. Recent literature contains extensive information on mass incidents (13). Disasters on a similar scale to that of the Love Parade 2010 include those at the Roskilde Festival in 2000, Brussels’ Heysel Stadium and Bradford in 1985, and Sheffield in 1989 (4). However, the number of publications on the subject that can actually be made use of seems to be relatively low (5). As yet the literature offers no structured evaluation of patient flows and diagnoses that also includes preparations for the actual event.

This article aims to provide a structured overview of the number, severity, and urgency of treatments and to assess the measures taken by hospitals, in order to provide a medical appraisal and thereby give the best possible recommendations for planning future mass events.

This paper does not investigate the causes of the disaster.

Methods

The treatment data (age, sex, time of presentation to hospital, department providing treatment, length of inpatient treatment, diagnoses according to ICD [International Classification of Diseases]) of the patients treated at the Duisburg hospitals involved was subjected to structured collation and evaluation. The authors assigned a severity level (1 = mild, 2 = moderate, 3 = severe) to each diagnosis.

Each diagnosis was also assigned to a field of internal medicine (cardiology, gastroenterology, neurology, pediatrics), surgery (trauma and visceral surgery, neurosurgery, ENT, ophthalmology, oral and maxillofacial surgery), or psychiatry. Intoxication due to use of psychoactive substances (ICD F10–F19.9) was assigned to internal medicine, because initial intensive care treatment for this is usually performed by internal medicine specialists.

The resulting data are shown using descriptive statistics. All relative values were calculated on the basis of the relevant samples. For example, the authors used all patients’ data to calculate main diagnoses but only patients with complete diagnosis statistics when calculating secondary diagnoses.

To evaluate the preparations made and the measures taken, the hospitals involved held a consensus conference three weeks after the Love Parade, and a written appraisal was compiled on the basis of questionnaires. This included an assessment of all the measures by consensus, using a Likert-type scale (essential, beneficial, no difference, not useful, counterproductive).

Patients were allocated to the Love Parade or to hospitals’ normal patient admissions on the basis of the emergency services’ transport reports and medical histories provided by patients and third parties. Only patients who were at the site of the Love Parade or immediately adjacent areas and whose first contact with a Duisburg hospital was after 9 a.m. on July 24, 2010 and before 9 a.m. on July 25, 2010 were included in the study.

Results

An estimated 250 000 people took part in the Love Parade 2010 (6). According to the emergency services’ plans there were 30 first-aid posts on site, each with capacity for 10 patients, as well as one on-duty physician, 20 first-aiders, and one ambulance, and in addition, two standard emergency treatment stations for 50 patients each (BHP 50, a category established by the German Institute for Standardization [DIN, Deutsches Institut für Normung]). These facilities registered a total of 5600 patient contacts over 24 hours. The 1600 members of auxiliary staff were increased to approximately 4000 after news of the mass panic was received. Seventy ambulances and other emergency vehicles and nine emergency helicopters were used.

All 12 involved hospitals took part in the retrospective assessment, with a total of 11 coordinators (some representing more than one hospital in the hospital network). Nine hospitals (75%) provided surgical care, two (17%) neurosurgical care, 10 (83%) internal medical care, and four psychiatric care. The evaluation of hospitals’ preparations is shown in the Box (gif ppt).

Overall, it was estimated that hospitals achieved maximum capacities with staff numbers between 2 and 2.5 times normal levels for 24 hours. Increasing staff numbers further using freelance physicians is of very limited benefit, as they are not usually familiar with local circumstances or activities.

In summary, a maximum of 29 inpatient beds plus five beds for observation and three for artificial respiration, were needed per hospital in connection with the Love Parade 2010.

Table 1 (gif ppt) presents the key data of the patients treated in Duisburg hospitals.

The distribution of main diagnoses by specialized field is shown in Figure 1 (gif ppt). This shows the number of patients treated in each specialized department. Where more than one department was involved, the department leading treatment was used.

Table 2 (gif ppt) shows the diagnoses grouped together by code. A single patient may have more than one diagnosis (e.g. multiple injuries to the extremities). The weighting of each diagnosis group in relation to the number of patients and the proportion of coded diagnoses is given here.

Table 3 (gif ppt) displays the distribution of main diagnoses in the three severity levels used. All patients were allocated to fields of internal medicine, surgery, or psychiatry according to their main diagnoses.

Figure 2 (gif ppt) shows the distribution of patients by field of internal medicine, surgery, and psychiatry and the distribution of severity levels in each one.

The average burden on hospital emergency rooms is shown in Figure 3 (gif ppt). Peak use was 20 patients per hour in one hospital, between 7 p.m. and 8 p.m.

Discussion

The medical and organizational measures taken in connection with the Love Parade 2010 are unusual compared to other large-scale tragedies. While most mass casualty incidents are dealt with by infrastructures operating as usual, before this event major preparations and arrangements were made, as considerable numbers of patients were anticipated even if the festival went smoothly.

On the basis of experiences in previous years, no glass items were allowed at the Love Parade and many patients were expected, particularly with diagnoses in internal medicine or associated with psychoactive substance use. After the morning and early afternoon passed as expected, there was a mass panic at around 5 p.m. in the area of the Karl Lehr Tunnel, resulting in a large number of deaths and injuries. Additional emergency service staff were brought in from reserve staff and extra treatment and care capacity was created to deal with the situation. The injured were then administered first aid on site and there was coordinated transport to hospitals in Duisburg and its surroundings, where further care was provided.

One factor in particular that considerably lessened the burden on hospitals was the smooth operation of the first-aid posts and emergency treatment stations set up on site, which dealt with high numbers of patients. Although they cared for only uninjured, exhausted festival participants and all patients with confirmed or suspected need for medical attention were transported to hospitals, these facilities allowed all those involved to concentrate on their own core skills and therefore made it possible to provide all patients with almost ideal care, given the circumstances.

Analysis of patient flows over time (Figure 3) shows that after the mass panic at 5 p.m. there was a decline in patient numbers, which did not reach their peak until between two and three hours later. This is because central first-aid posts were set up on site (712) and there was then organized patient transport from the site, in accordance with current recommendations (1315). However, there was no perceptible reduction in the burden on hospitals as a result of the low number of patients in the first hours, because although fewer patients were initially transported, those who were transported were more seriously injured. The immediate formation of trauma teams (16) and preparation of other (emergency) trauma rooms made it possible to control patient flows appropriately in all hospitals.

Although preparation on the basis of experience from previous Love Parades in Dortmund and Essen (estimated 80% of emergencies relating to internal medicine, 20% to surgery) concentrated on internal medicine, the events themselves required considerably higher levels of surgical diagnosis and treatment (Figure 2). Although in retrospect there was a comparatively high proportion of patients with minor injuries (Table 3), in a majority of these patients severe blunt trauma (intra-abdominal bleeding, hemothorax/pneumothorax, pulmonary contusion) had to be ruled out, requiring full trauma room diagnostic examination. For this reason, the injury severity as finally diagnosed is not an appropriate measure of initial consumption of medical resources, which must be considered significantly higher.

The high proportion of patients diagnosed with abuse of or intoxication from psychoactive substances demonstrates drug problems. The essential difficulty here was the large number of cases; significant problems in the form of complex multiple intoxication with indistinguishable symptoms did not occur, which meant that suitable treatment could be provided by physicians who were not specialists in treating psychoactive substance intoxication. Previous advanced drug training was rated as important and positive. On the one hand, this means physicians have more in-depth specialized knowledge, and on the other it dispels uncertainties when dealing with patients (which slow down the work) and so speeds up decisions and processes. As swift treatment of such patients is a high priority, this advanced training should be recommended when preparing for other, similar events.

Work was made substantially easier by the fact that the patient population was young (median age 23.0 years) and healthy. Codes for significant pre-existing secondary diagnoses were given for only 9 patients (2.6%). Although this does not rule out the existence of other secondary diagnoses, these did not cause any consumption of medical resources. On the one hand this means patients could be treated swiftly, but on the other it does not release staff from their duty to take a complete medical history to ensure that no relevant information is overlooked. For example, drug allergies were not recorded for all patients. This means that the total proportion of patients with significant secondary diagnoses should be assumed to be higher.

The chief problem in internal medicine was psychoactive substance abuse, which was present in 29.6% of patients. Although psychoactive substance abuse itself often does not require treatment, it does affect patients’ diagnoses and compliance, meaning that other symptoms may be overlooked. This is also the reason for the high number of inpatients signing out of hospitals against medical advice.

Turning to surgery, superficial wounds and injuries to the extremities were very common. The main problem, however, was not treating these injuries but ruling out serious injury in a large number of patients. There are no codes for this. In comparison, less medical resources were consumed by the actual care provided for injuries. It is therefore important that emergency plans include adequate rapid structures and that they are made as efficient as possible when preparing for mass events (16, 17) so that there are sufficient resources available for the actual treatment required by the injured.

A weak point of the research might be the incomplete nature of the database, the result of different hospitals transferring different scopes of data. However, at least three quarters of all patient data were successfully collated in all areas. In our opinion, the high number of patients and the qualified evaluation of the data by experienced physicians mean that valid conclusions can be drawn from this data pool. The literature contains no previous statistics on mass disasters with comparable levels of detail.

In retrospect, the measures taken in all fields seem to have been sufficient. Even peak demand was dealt with appropriately by hospitals and the emergency services. The many hospital employees who spontaneously travelled to their places of work after hearing of the disaster and provided support deserve praise.

Overall, hospitals achieve maximum capacities with staff numbers between 2 and 2.5 times normal levels. Local hospitals cannot deal with higher demand. It should be debated whether organizers or authorities granting authorization ought to be informed and whether logistical and financial assistance ought to be demanded.

The communication policy surrounding the event is also subject to criticism. It is quite clear that the participant numbers reported in Duisburg were substantially exaggerated, as they had been for the events in Essen and Dortmund. This makes it impossible to plan hospital capacities realistically. The lack of accurate reporting results in an additional risk, because when past figures based on falsely high numbers of participants are reviewed the treatment capacities for future events are planned for insufficient numbers, endangering patients.

A central aspect of future common preparations must therefore be comprehensive, accurate information from hospitals and physicians involved.

Medical practices

While hospitals are always involved in providing care, physicians with their own practices are only affected in the few cases in which a mass event is held during regular consultation hours. Because of their longer opening hours, surgical insurance accident consultants’ practices are particularly likely to be affected, and they should therefore also make preparations. Plans must be based on the premise that the emergency services’ transport capacity will be severely limited. This means there should be clear arrangements for admission to collaborating hospitals. Routine appointments should be avoided, and an experienced employee should be designated for patient admission and triage. It is advisable to inform patients already in the waiting room in advance. Rapid wound care and plaster casting techniques may also be advantageous.

Summary

Patient care by hospitals and the emergency services was adequate. The main clinical factors were consumption of psychoactive substances and the high number of patients with potentially serious injuries.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 22 November 2010, revised version accepted on 7 February 2011.

Translated from the original German by Caroline Devitt, MA.

Corresponding author
Dr. med. Ole Ackermann MaHM

Klinikum Duisburg

Zu den Rehwiesen 9

47055 Duisburg, Germany

ole.ackermann@klinikum-duisburg.de

1.
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Jasper U: Untersuchung des Verwaltungshandelns auf Seiten der Stadt Duisburg anlässlich der Loveparade. Zwischenbericht 3.8.2010. http://www.scribd.com/doc/36115433/Zwischenbericht-Loveparade-von-Dr-Ute-Jasper-txted.
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9.
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Sefrin P: Notfallmedizin – Sichtung als ärztliche Aufgabe. Dtsch Arztebl 2005; 102(20): 1424–8.
11.
Sefrin P, Weidringer JW, Weiss W: Katastrophenmedizin – Sichtungskategorien und deren Dokumentation. Dtsch Arztebl 2003; 100(31–32): 2057–8. VOLLTEXT
12.
Adams HA, Mahlke L, Lange C, Flemming A: Medizinisches Rahmenkonzept für die überörtliche Hilfe beim Massenanfall von Verletzten (Ü-MANV). Anästhesiol Intensivmed 2005; 46: 215–23.
13.
Luiz T, Kumpch M, Laux T, Madler C, Förster P: Medizinische Gefahrenabwehr anlässlich der Fußballweltmeisterschaft 2006. Notfall Rettungsmed 2006; 9: 248–57.
14.
Flemming A, Adams HA: Rettungsdienstliche Versorgung beim Massenanfall von Verletzten (MANV). Intensivmed 2007; 44: 452–9.
15.
Adams HA, Mahlke L, Flemming A, Probst C, Tecklenburg A: Katastrophenmedizin – Konzentration aller Ressourcen. Dtsch Arztebl 2006; 103(6): 314–8. VOLLTEXT
16.
Probst C, Hildebrand F, Gänsslen G, Krettek C, Adams HA: Der Notfallplan des Krankenhauses bei Massenanfall von Verletzten (MANV). Intensivmed 2008; 45: 40–50.
17.
Adams A, Altheim C, Knopf S, et al.: Erfahrungen anlässlich des Expertenpanels „Fußball-WM Deutschland – Medical Lessons Learned“, 6. 10. 2006, München – Berichte aus den 12 Austragungsorten. Notfall Rettungsmed 2007; 10: 13–22.
Klinik für Orthopädie und Unfallchirurgie, Klinikum Duisburg und Berufsgenossenschaftliche Unfallklinik Duisburg-Buchholz, Duisburg: Dr. med. Ackermann
Malteserkrankenhäuser St. Anna und St. Johannes-Stift, Duisburg und Klinik für Orthopädie, Universitätsklinik Ernst-Moritz Arndt Universität Greifswald: Prof. Dr. med. Lahm
Medizinische Klinik I, Evangelisches Krankenhaus Bethesda zu Duisburg GmbH, Duisburg: Prof. Dr. med. Pfohl
Klinik für Anästhesiologie und Intensivmedizin, Evangelisches Krankenhaus Bethesda zu Duisburg GmbH, Duisburg: Dr. med. Köther
Abteilung für Anästhesie und Intensivmedizin, Johanniter Krankenhaus Rheinhausen, Duisburg: Lian
Abteilung für Anästhesiologie, Intensivmedizin und Notfallmedizin, Evangelisches Krankenhaus Duisburg-Nord, Duisburg: Dr. med. Kutzer
Klinik für Anästhesiologie und Intensivmedizin, Katholisches Klinikum Duisburg, Duisburg: Dr. med. Weber
Ärztlicher Leiter Rettungsdienst, Feuerwehr Duisburg, Duisburg: Dr. med. Marx
Klinik für Orthopädie und Unfallchirurgie am St. Josef Hospital Bochum – Klinikum der Ruhr-Universität-Bochum: Dr. med. Vogel
Berufsgenossenschaftliche Unfallklinik Duisburg-Buchholz: Dr. med. Hax
1.Hüls E, Oestern HJ: Die ICE-Katastrophe von Eschede, Erfahrungen und Lehren – Eine interdisziplinäre Analyse. Berlin, Heidelberg, New York: Springer 1999.
2.Hill IR,Howell RD, Jarmulowicz M: Identification in the Manchester air disaster. Br Dent J 1988; 165: 445–6. MEDLINE
3.Holzer FJ, Patscheider H: Das Flugzeugunglück in Innsbruck. Dtsch Z Gesamte Gerichtl Med 1966; 57: 133–44. MEDLINE
4. Sharpe DT, Roberts AHN, Barclay TL, et al.: Treatment of burns casualties after fire at Bradford City football ground. Br Med J 1985; 291: 945. MEDLINE
5.Oestern HJ, Hüls E: Frühere Katastrophen im Vergleich zu Eschede. Notfall & Rettungsmedizin 1999; 2: 349–52.
6.Jasper U: Untersuchung des Verwaltungshandelns auf Seiten der Stadt Duisburg anlässlich der Loveparade. Zwischenbericht 3.8.2010. http://www.scribd.com/doc/36115433/Zwischenbericht-Loveparade-von-Dr-Ute-Jasper-txted.
7.Sefrin P: Die Rolle des Behandlungsplatzes bei Massenanfall von Verletzten. Am Beispiel der Vorbereitungen für die Fußballweltmeisterschaft 2006. Notarzt 2005; 21: 189–94.
8.Kanz KG, Hornburger P, Kay MV, Mutschler W, Schuble W: mSTaRT-Algorithmus für Sichtung, Behandlung und Transport bei einem Massenanfall von Verletzten. Notfall Rettungsmed 2006; 9: 264–70.
9.Adams HA: Patientenversorgung im Katastrophenfall – Stellungnahme der Interdisziplinären Arbeitsgruppe (IAG) Schock der Deutschen Interdisziplinären Vereinigung für Intensivmedizin und Notfallmedizin (DIVI). Unfallchirurg 2006; 109: 583–6. MEDLINE
10. Sefrin P: Notfallmedizin – Sichtung als ärztliche Aufgabe. Dtsch Arztebl 2005; 102(20): 1424–8.
11.Sefrin P, Weidringer JW, Weiss W: Katastrophenmedizin – Sichtungskategorien und deren Dokumentation. Dtsch Arztebl 2003; 100(31–32): 2057–8. VOLLTEXT
12.Adams HA, Mahlke L, Lange C, Flemming A: Medizinisches Rahmenkonzept für die überörtliche Hilfe beim Massenanfall von Verletzten (Ü-MANV). Anästhesiol Intensivmed 2005; 46: 215–23.
13. Luiz T, Kumpch M, Laux T, Madler C, Förster P: Medizinische Gefahrenabwehr anlässlich der Fußballweltmeisterschaft 2006. Notfall Rettungsmed 2006; 9: 248–57.
14. Flemming A, Adams HA: Rettungsdienstliche Versorgung beim Massenanfall von Verletzten (MANV). Intensivmed 2007; 44: 452–9.
15.Adams HA, Mahlke L, Flemming A, Probst C, Tecklenburg A: Katastrophenmedizin – Konzentration aller Ressourcen. Dtsch Arztebl 2006; 103(6): 314–8. VOLLTEXT
16.Probst C, Hildebrand F, Gänsslen G, Krettek C, Adams HA: Der Notfallplan des Krankenhauses bei Massenanfall von Verletzten (MANV). Intensivmed 2008; 45: 40–50.
17. Adams A, Altheim C, Knopf S, et al.: Erfahrungen anlässlich des Expertenpanels „Fußball-WM Deutschland – Medical Lessons Learned“, 6. 10. 2006, München – Berichte aus den 12 Austragungsorten. Notfall Rettungsmed 2007; 10: 13–22.