Skip to main content

MCI Training at the FDNY MSOC

On May 16–19, 2019, the Fire Department of New York (FDNY), in partnership with the FDNY Foundation, invited first responders from around the world to its seventh annual Medical Special Operations Conference (MSOC), a series of workshops, lectures, panel discussions, and hands-on skills scenarios focused on training for mass-casualty incidents. MSOC is an elite gathering of military, federal, state, and local medical responders sharing their experiences, best practices, and ideas.

Each year MSOC evolves to include current hot topics, the latest medical technological updates, and recent case studies from around the world. EMS World was granted exclusive access to the event. View behind-the-scenes photos here and enjoy the following bonus MCI response and rescue content. 


The Thai Cave Rescue: Operation Wild Boar 

How an international effort saved a youth soccer team

On June 23, 2018, the Wild Boars soccer team and their coach became trapped in the Tham Luang cave, located in the Chiang Rai province of Thailand. After soccer practice that day, the boys had gone exploring in the underground maze, a common pastime of theirs. But heavy rains led to rapid flooding, forcing the boys more than three miles into the cave to avoid drowning.1 All 12 children and their coach were rescued after 17 days. Stephen Rush, MD, medical director for the U.S. Air Force pararescue team, discussed obstacles faced by the international search and rescue team and the methods used to successfully execute their mission. 

Key Point #1: Press on when there is no solution in sight.

  • Rescuers planned as if they would find the team when it was not known whether they were alive. 
  • PJs provided support to Thai leadership on planning, organization of disparate groups, and oversight of execution.
  • A British expatriate provided maps of Tham Luang cave.
  • A Thai geologist determined how to divert and pump waters from above. 
  • British rescue cave divers had the necessary skills. Overhead cave diving entails more complex skills than those of open-water diving.  
  • The coach kept the boys calm by teaching them meditation. 

Key Point #2: Ask, “In a perfect world, what would you want?”

  • A Thai general approved enlistment of world’s three best cave divers. 
  • They brought in Australian cave diver/anesthesiologist Dr. Richard Harris. 
  • PJs, Seals, Brits, and Australians were assigned different tasks. 
  • All parties reached consensus in developing the plan. 

Key Point #3: Define and mitigate the risks; execute rehearsals in detail.


  • No one had performed a cave dive rescue for nondivers, and the kids couldn’t swim. 
  • For divers, entanglement, high-voltage lines, rocks hitting heads or snagging air lines, hypothermia. For the children, malnourishment, sedation delivery, monitoring by nonmedical personnel.

Mitigation and rehearsals:

  • A contingency plan for divers: lost line procedures, mask flooding, running out of air; prepared to get kids out even if they died along the way. 
  • Seals practiced with local kids in pools—fitted them with wetsuits and positive-pressure masks.
  • Harris examined the kids and strategized sedation dosages (alprazolam, atropine, ketamine); these were reviewed by a pediatric anesthesia professor.


  • The kids were sedated, put in wetsuits and full face masks, with positive pressure, air tanks filled with maximal oxygen (80%).
  • Divers brought two tanks for each child and staged one halfway to swap out. Kids were reevaluated in dry areas.
  • Divers rescued four kids per day (the time between each rescue prevented bottlenecks in case of mishap and allowed changes to improve the process between each child).


1. BBC News. The full story of Thailand’s extraordinary cave rescue; 2018 Jul 14; 


TARMAC Attacks: 10 Things to Know

In the last decade the world has seen an increase in attacks on civilians by way of vehicles plowing into crowds on streets or at large gatherings. James Phillips, MD, FACEP, chief of disaster and operational medicine at George Washington University, refers to these events as TARMAC (targeted automobile ramming mass casualty) attacks. In his talk he discussed their characteristics and the unique approach required to manage them.

1. The public thinks the future of terrorism consists of lone wolves with IEDs, but the trend is actually low-tech, high-impact attacks (e.g., mass shootings/stabbings, TARMAC attacks) because they don’t require training, restricted materials, or intricate conspiracies. 

2. There has been a paradigm shift in attacks:

  • Airline/transportation bombings: 1970s–1990s
  • Suicide bombings: 1980s–present
  • TARMAC attacks: 2010–present

3. “The Ultimate Mowing Machine,” a 2010 article published in al-Qaeda’s magazine Inspire, detailed how to acquire a vehicle to kill the greatest number of people. “Just Terror Tactics,” published in 2016 by the ISIS magazine Rumiyah, provided similar instructions. TARMAC attacks increased around the world following their publications.

4. Only 35% of TARMAC attacks are associated with terrorist or hate groups. Mental illness sometimes plays a role. Many motives are unknown.

5. TARMAC trauma is unique; intentional mass blunt trauma MCIs are otherwise unknown. Blunt trauma injury patterns seen in pedestrians struck by vehicles with braking drivers are much different from those of an intentional ramming. 

6. Prevention and mitigation: Bollards and jersey barriers surrounding crowds or in front of buildings can block vehicles. Dump trucks, buses, and snowplows can serve as alternatives. Deployable metal net road strips utilize hypodermic needles that puncture tires and get wrapped up into a vehicle’s axle.

7. Prevention only works to a point, so focus on patient care. EDs should be prepared with ultrasound machines. Imaging tests are crucial to quickly detecting internal bleeding and organ/head/c-spine injuries. To save time with a large influx of MCI victims, CT-scan the head and c-spine only, e-FAST (ultrasound) the rest, and treat. CT the thorax and abdomen later, once CNS imaging for all has been completed.

8. Phillips and his research team have created the Global TARMAC Attack Database. Data includes the number of injured, type of vehicle used, attack motive, and victim demographics. Its intent is to identify patterns so physicians and medics can better prepare. This searchable online database will go live soon. 

9. In March a computer engineer and ISIS sympathizer was arrested before attempting to commit a TARMAC attack in Washington, D.C. He stole a van and searched for a large crowd. Unsatisfied with his search, he broke into a boat in National Harbor, Md. to carry out the attack the following morning. Someone called police and he was arrested.

10. Bottom line: The future of terrorism is low-tech, homegrown, violent extremism against poorly defended pedestrians using guns, blades, and automobiles. Prepare accordingly.

—Valerie Amato, NREMT 

Back to Top