The involvement of dignitaries within mass gathering events can often impose several difficult levels of complexity, both during the planning phases and throughout the event itself. Whether the dignitaries are the reason for the mass gathering or they are on location as additional special attendees of the event, so-called “very important persons” (VIPs) such as celebrities, royalty, or major political figures can affect the planning and preparations for medical management contingencies as well as the operational aspects of such events [1–3]. Beyond the typical challenges of mass gathering medicine and protective security aspects, the concepts and practice of executive medicine, concierge medicine, or “protective medicine” pose unique and often unfamiliar and uncomfortable adaptations in terms of delivering medical advice and care. Medically, there is often limited access and reticence to expose the VIP to unfamiliar practitioners. Requests for medications or therapies in the absence of directly seeing the patient is more common. There is also an expectation that the medical care provider will come to see the VIP at the site and not at an off-site medical facility.

For large entertainment tours composed of 100 to 200 personnel moving from one city (or country) to another every few days over several months’ time, the odds of numerous untoward health events occurring, some very serious, become reasonably high. Beyond rigorous schedules and living/dining in close quarters, understandable reticence to abandon one’s post can occasionally delay timely care. Accordingly, having veteran medical specialists as part of the touring team has been found to be invaluable, not only for pre-emptive minor interventions and continuity of care, but also for immediate, expert handling of serious emergencies. Experienced, well-connected touring medical specialists also provide prospective contingency plans for each destination city and venue. These medical advance plans detail the most-knowledgeable local physicians or facilities for best managing any respective medical condition. They also identify the local “point-persons” to contact for coordination of true emergencies and especially if there is a need for multi-casualty incident management at the venue. They anticipate health risks such as air quality, altitude sickness, endemic disease vectors and other concerning threats at each destination. They also train touring staff in basic life support, bleeding control and emergency equipment readiness. Touring specialists should also be well-integrated into security team functions.

Civil unrest or terrorism at mass gathering events can erupt with significant violence and multiple casualties. These are high-risk situations, not only because of physical casualties, but also because of ethical, political and psychological sequelae. Beyond specialized planning, multi-agency drills and proficient tactical medicine training, medical teams should co-create secured access and egress, alternative medical responses and rapidly-adapting coordination and secure communications with other agencies. Civil protests can escalate, especially when extremist groups infiltrate them. Multi-site violence and assaults can evolve, particularly in terroristic attacks. Key lessons include unrelenting vigilance until all participants have left the mass gathering scene in its entirety. Violence (bombs, shootings, vehicle attacks) will often erupt when mass gatherings are dispersing and considered over. Terrorists can also purposely target medical personnel or incite one event (fire, bomb, shooting) to create crushing stampedes or to herd crowds into more vulnerable areas where they can be further attacked more directly with other modern weapons. Terrorists often attack from elevated perches or generate “protracted suicide” incidents while holding hostages, including many severely-wounded. The resulting frustration, anger and guilt commonly can consume medical rescuers when beholding slaughtered innocents or simply because they were (appropriately) staged during containment of on-going violence.

While all mass gatherings create significant challenges for delivering optimal medical care, music concerts and festivals engender additional concerns ranging from a higher likelihood of toxicological, topographical, meteorological and sociological risks to additional threats from violence, injury and even food-borne illness. Locating patients can pose challenges among packed audiences in the dark and din of massive crowds and blaring entertainment. Multi-day music-related festivals, particularly those including on-site overnight camping, can pose additional and often escalating risks day-by-day.

Planning risk assessments can be multi-variate and dynamic in nature. Medical planners may first tailor plans based on historical experiences, evolving new intelligence or even developing external threats, but available tools for calculating risk for each type of threat can better quantify concerns and justify additional funding and resources for the best possible medical care and health security. Beyond basic considerations such as estimated crowd size and density, location of the venue, and event-specific medical considerations, mass gathering medicine clinicians and planners need to navigate some variable considerations including climate, weather, type of event, specific site structures, the organizers’ expectations and even typically unanticipated types of events such as terrorism, stampedes, contaminated food and some previously-unrecognized lethal drugs being passed around to attendees.

Mass gatherings create challenges to timely medical response. These challenges become amplified when medically and sociologically vulnerable individuals attend. Such at-risk persons may include, but certainly are not limited to, pregnant women, children, the elderly, people with chronic medical conditions, and those with one or more forms of disabilities. When planning for mass gatherings, or when directly managing large assemblies of persons that have evolved subsequent to mass evacuations of displaced persons retreating from a disaster, military conflict, or other humanitarian crisis, experience has shown that prospective preparedness and contingency planning addressing the needs of the entire community, including at-risk populations, facilitates better outcomes for all. Depending on the specific mass gathering, there will always be a variation in the unique concerns, event-driven nuances and potential at-risk populations in attendance for each. However, one recommended generic strategy to help provide a more unified and methodical approach to planning for at-risk persons is the Communication, Maintaining Health, Independence, Support and Safety and Transportation (CMIST) Framework. The CMIST framework has been shown to an extremely useful tool that can help event organizers and emergency managers better anticipate the various needs of these at-risk populations under a variety of mass gathering scenarios worldwide.