Background The emergency medical services (EMS) system is critical to organising and responding to mass gathering events. Multiple studies discuss the factors/variables that affect patient presentations in various mass gathering settings, but with a minimum focus on the operational side of the EMS system. The present study explores the process of EMS provision during an international mass gathering event: the Hajj.

Methods The study utilised interview data collected in two consecutive Hajj seasons, prior to the COVID-19 outbreak, with EMS leaders, infield supervisors, clinicians, police, and emergency planners at three Hajj sites (i.e., Arafat, Mina, and Muzdalifah). Also used were the principal investigator’s notes of non-obtrusive observations on the EMS delivery process and gathering people’s interactions with ambulances. The inductive analysis helped to understand the operational elements within the EMS provision and the effects of organisational factors.

Results EMS centres and ambulances near and within hot zones increased patients‘ accessibility to prehospital care, but the challenges of ambulance transportation for critical patients who needed urgent medical attention remained. Police-managed traffic control points hindered ambulance movements in many instances. The Hajj mass gathering of multicultural people follows a relatively strict timetable to perform their ritual duties, which enhances high-density hot spot formation and increases demands on EMS. EMS clinicians find that the language barrier significantly affects the provided medical services. The delay in ambulance service response and patient transportation time is of primary concern for EMS clinicians in the Hajj sites.

Conclusion Redesigning EMS operations in the Hajj sites is needed considering the factors mentioned above. Researchers from the Mass Gathering Medical Care (MGMC) field should investigate the operational components of the EMS system and organisational factors affecting EMS provision within mass-gathering contexts.