Hannah Meeks, a registered nurse, and Deb Poquette, director of community outreach and health equity at the Centennial Medical Group, inspect a first aid kit before the 148th Preakness Stakes at Pimlico Race Course in Baltimore last month. (Michael A. McCoy for The Washington Post)

It takes a lot to faze an emergency medicine doctor, but the “smurfs” did it for Taylor Burkholder.

Since last summer, the 36-year-old emergency physician at the University of Southern California has worked at least four music events in California where concertgoers came into the medical tent having turned a blue-gray color that reminded him of the cartoon characters.

Turns out, Burkholder says, they’d gotten sick by ingesting — instead of inhaling — amyl nitrate “poppers,” which can cause a potentially life-threatening condition called methemoglobinemia that deprives the body‘s tissues of oxygen.

“​That’s why they quickly turn an ashy blue color​,” Burkholder says. “It’s a bizarre sight.” He gave the patients supplemental oxygen and sent them to a nearby hospital right away, in most cases using an ambulance on-site.

Blue patients, drunken falls, overheated dancers, it’s all in a day (and night) for medical workers at live events.

These workers — doctors, nurses and other emergency medical staff — say they are drawn to gatherings year after year by the adrenaline and the “MacGyver Med” vibe at big events sometimes held in deserts, fields and empty airplane hangars. The money doesn’t hurt, either, with doctors saying they get paid the same rate as an emergency department shift in a hospital.

“It’s a very different slice of medicine,” says Jessica Osterman, an emergency medical physician at the University of Southern California who has worked in festival medicine since 2014, including at the Coachella music festival before the pandemic. “You get to practice based on very little information and few resources, so it’s an interesting use of your skills as an ER physician.”

Field hospitals, stitches and cooling tanks

Over the past 20 years, “event” med has come a long way.

“At some festivals the medical tent will have up to eight critical care beds with the ability to intubate people and put them on breathing machines,” says Burkholder, adding that tents also usually have huge tanks filled with ice and water for dunking people whose body temperatures get too high because of drug use or the heat.

A big event might even have its own field hospital staffed with up to 60 registered nurses and emergency medical technicians and paramedics, as well as physicians trained in emergency medicine and toxicology.

“We can do sutures or give antibiotics or tetanus shots, and we can treat allergic reactions and asthma exacerbations,” he says. “It’s not the same as being in an actual emergency department, but it’s as close as we can get it.”

Big concerts have offered some medical services for decades — in 1969, Woodstock’s emergency medical services coordinator had three ambulances on-site, and planned to have at least two doctors and four nurses on duty around-the-clock, according to the Journal of Emergency Medical Services.

Evolution of on-the-scene care

Large-event medical services started becoming more formalized about 20 years ago, with the implementation of the National Incident Management System following the Sept. 11, 2001, attacks, says George Chiampas, an assistant professor and attending physician in emergency medicine at Northwestern University and Northwestern Memorial Hospital.

Medical services also evolved as more concerts grew into multiday events. The big change came with Lollapalooza, an annual three-day summer music festival in Chicago, which typically hosts about 400,000 concertgoers.

Chiampas became medical director of the Chicago Marathon in 2007, and the city asked him to work with Lollapalooza in 2014 after ​officials ​not​ed​ “a significant number of hospital transports.”

​“They were relying solely on ambulances and the local EMS system; they didn’t have a medical tent to take care of people on-site,” says Chiampas, who is also director of Northwestern’s Disaster Management and Community Emergency Preparedness Initiative. “And the reality is that hospitals are already at capacity, so then you’re adding 50, 60, 80 transports in the span of five or six hours every night of an event, you’re essentially overwhelming the local emergency rooms.”

Now Lollapalooza has a major medical tent and takes care of people on-site, he says, adding that medical services will cost from $25,000 to $150,000 for the staff ​and setup over four or five days, ​ depending on the number of staff and extent of​ resources​ needed. The cost is built into the ticket.

Korin Hudson is an emergency physician with MedStar Health and a professor of clinical emergency medicine at Georgetown University School of Medicine. She first started working at events as an EMT in 1997 while she was a student at the University of Virginia in Charlottesville.

By looking at similar events, and data collected about the number of patients and injuries from past years, she says, medical teams can make projections of what they’ll need for upcoming events based on the size, average age of attendees, and whether it’s a sporting event or a concert.

Handling large crowds, preparing for the worst

Large events such as NASCAR races and the Preakness, which can draw tens of thousands of spectators, typically use bike teams and all-terrain vehicles to move around more easily, says Hudson, who worked at the Preakness in Baltimore in May.

“We’ll have a two-person EMT team or medic EMT team, and they’ll rope through the crowd on bicycles with equipment — an AED and a standard EMS ‘junk bag’ of equipment — and they can kind of go through the crowd looking for trouble,” Hudson says.

Doctors can expect certain things — heat exhaustion in a desert setting, for example, as well as falls and other accidents, but Osterman says it’s when the unexpected happens — such as heart attacks or aneurysms — that she really gets to stretch her skills. And then there are the special cases such as the intoxicated concertgoer who dove into a freezing cold lake after deciding — wrongly — that he was in the middle of a desert.

“We had eight different people trying to get him out of the lake, and he was like, karate fighting all of them, so we basically had a midwater takedown of this guy to get him out safely and into the medical tent,” she recalls.

John Roussis, an EMT, is president of Event Medical Staffing Solutions in Sharon Hill, Pa., and calls himself a “mass gathering specialist.” His company has helped organize the Firefly Music Festival in Delaware in the past.

One thing that’s front of mind for medical event staff is preparing for mass casualty events, whether because of a shooting such as the one in 2017 at the Route 91 Harvest festival in Las Vegas that left 60 people dead and almost 500 injured, or a stampede like the one at the Astroworld Festival in Houston 2021, where 10 people were killed.

“In those situations, there’s a heavy, heavy reliance on the public to self-sustain for a period of time, which means we need to train them to stop bleeding, or do CPR, and when to activate 911,” Roussis says, adding that many venues now have “Stop the Bleed” kits in the same location as defibrillators.

Doctors and event organizers said festivalgoers should make sure to check out where medical tents are located when they arrive, and consider bringing their own first-aid kit and a couple days of their medications if they are going to a festival.

After working a couple 12-hour shifts in a row, often in challenging weather, medical staff are often exhausted.

It’s worth it, says Osterman, adding that such work is usually less stressful than a shift in the ER and comparably paid. And, then there are perks you can’t get in any other type of medicine.

At Coachella, members of the medical staff receive a “behind-the-scenes production pass,” says Osterman, who missed working her dream concert — Beyoncé headlining Coachella in 2018 — only because she was pregnant. She’s already planning ahead: “I need to do this for Beyoncé, because that is my dream come true.”