Adrenaline, preparation, precision: Inside the city-wide FIFA World Cup 2026™ major training simulation
On a bright sunny day in late June, an impromptu parade breaks out in downtown Toronto.
Strachan Street teems with soccer fans as they slowly make their way towards the Toronto Stadium (BMO Field) at the Exhibition Grounds, where the city is hosting several games as part of the FIFA World Cup 2026™ soccer matches.
Somewhere in the distance, a group begins to light off contraband fireworks. Several malfunction, firing directly into the crowd. Panic sets in.
Had this event actually happened, it would have been a massive public safety incident, leading to injuries and trauma. Instead, this fictional story served as the training scenario for Operation Red Card, a city-wide emergency preparedness exercise intended to test the limits of coordination and capacity between no less than 32 provincial health organizations as they prepare for the more than 300,000 visitors expected to attend the June celebrations.
Response teams across different sites say there is increasing pressure to make these programs a staple of the city’s coordinated response training.
“The more we work together to be able to function as one connected network, the more likely we're going to be successful,” says Avery Nathens, director of the American College of Surgeons Trauma Quality Improvement Program and the director of the Tory Trauma Program at Sunnybrook Health Sciences Centre.
Nathens, who is also a professor of surgery at the University of Toronto’s Temerty Faculty of Medicine, has seen the importance of training firsthand. Among other major incidents, he led the Sunnybrook trauma response to the Toronto van attack in 2018, which killed 11 pedestrians and injured another 15.
“We’re looking at not only how can we move patients through the network, but how can we better support care locally at other hospitals? How can we extend our network so that care can be provided in a larger spectrum of facilities?”
Toronto trauma centres – Sunnybrook, Unity Heath Toronto’s St. Michael’s Hospital and The Hospital for Sick Children (SickKids) – will routinely hold major trauma simulations several times a year. Called a “Code Orange”, these internal scenarios keep trauma centres prepared for major incidents. Operation Red Card, however, extended this drill past the capacity of a single centre, requiring coordination between all hospitals in the city, first responder teams and even community sites.
“Toronto hospitals are the best in the world, they're second to none,” says Moira Hennebury, Manager of Emergency Preparedness at Sunnybrook. “Operation Red Card was about coming together and verifying our ability as one system to manage a major response, because that's what the public expects of us.”
Training Day
On April 15th, response teams set up in hospitals and offices across Ontario.
In the auditorium at Sunnybrook, every team was designated their own table or “department” – the emergency department table and trauma team, the OR table, ICU tables, radiology and so on. Hospital Family Information and Support Centres also coordinated at the various hospital sites, simulating work reuniting families with patients spread across the network.
Each table was equipped with a floor plan of their unit and game pieces representing not just the staff and patients, but equipment like ventilators, blood banks and even phones. Overhead pages helped staff track what was needed in other areas of the “hospital,” just as how the real emergency department would function.
“You couldn't cut corners,” explains Corey Freedman, Sunnybrook’s Trauma Service manager. “If you wanted to call someone you had to make sure you had a phone piece and you were calling someone else with a phone piece.”
The exercise began at 8:30 a.m., when a news report was sent to each training site, giving a vague update of an incident close to Toronto’s Exhibition grounds. The total number and nature of injuries remained unclear. Soon, teams began to receive “injects,” cards with new information describing each mock patient and their injuries – from burns to physical trauma caused by hundreds of terrified, fleeing soccer fans.
Patient injects were tracked through the hospital boards just as they would be in a real emergency department, with each team running through their treatment protocols and interacting with the equipment where it was stationed on the hospital boards. Hand-offs between teams required available space and someone to accept responsibility for the new case.
Attendees later described the energy in the room as similar to what they feel in the emergency department on a busy night – balancing adrenaline and stress, while relying on structured communication systems to hold back a sense of overwhelm.
“You're diving into figuring out how you clear and decant the emergency department, how you assemble your teams to get ready for incoming patients,” says Suzanne Beno, medical co-director of SickKids’ Trauma Program and emergency physician and associate professor of paediatrics at Temerty Medicine. “You’re alerting key hospital response areas, ensuring your surgical leads are present, and rapidly doing a lot of prep in a short amount of time.”
To simulate a functioning hospital, each site also included the patient volume already recorded at each emergency department.
“We started with a real-life occupancy on the day of this tabletop, [in which] we were already at 125 per cent capacity at Scarborough Health Network,” says Mayoorendra Ravichandiran, deputy chief of emergency medicine at Scarborough Health Network and a lecturer at Temerty Medicine. “And then we started to take in patients.”
In total, the teams handled 277 patient injects across 18 emergency departments – 275 from the simulated casualty event, and two non-related cases in need of critical care. An additional 507 family injects simulated those people looking for their family members brought to hospitals or lost in the chaos.
The high volume of injects required each team to shift their emergency care practices to a more controlled, resource-conscious approach.
Under normal circumstances in the emergency department, a trauma surgeon is stationed to evaluate patients and coordinate what treatment or specialist they need. Calls go through quickly; staff are available almost immediately to whisk the patient away for CT scans or to be prepped for surgery. In the context of a major incident, this approach must change. Using a CT scanner for one patient means the next patient coming in may have to wait.
“You're really trying to make sure the most time-sensitive conditions and patients get the resources they need at the earliest opportunity,” explains Nathens.
“Typically, the patients that come in first are less severely injured. So, you want to make sure you're deploying the team in a way that's going to ensure the best possible outcomes for as many patients as possible.”
Cross-Toronto Collaboration
Throughout the city, health-care sites are grouped based on the specific roles they play to serve the community, including non-acute sites (for medical, rehabilitation and longer-term supportive services) and acute and urgent care centres (providing short-term treatment for severe injuries, sudden illnesses and post-surgery recoveries). Trauma centres are responsible for treating the most serious injuries and maintain 24/7 access to specialized experts, including neurosurgeons, trauma surgeons, radiologists and critical care teams.
An incident with a high number of cases will require significant coordination across categories, ensuring no team becomes overwhelmed and each patient gets the care they need.
“You can’t just send all patients to the closest hospital to the incident, because many likely have injuries that needs a trauma team,” says Rob Fowler, chief of Sunnybrook’s Tory Trauma Program and the H. Barrie Fairley Professor of Medicine at Temerty Medicine. “So, the question becomes how much can you spread cases out without overwhelming any particular place, and how do you get patients to places that can handle their needs safely?”
“You may look at your roster of patients who have come in and say, for example, Scarborough Health Network has great orthopedics care, great general surgeons,” adds Nathens. “Is there an opportunity to triage a spectrum of patients to them from our Emergency Department?”
During the Operation Red Card simulation, patient injects didn’t always arrive at the most appropriate site. While most were coordinated through the Toronto Paramedic Services, some were walk ins – like a paediatric inject that first sought care at Sunnybrook. The team stabilized the young patient and then coordinated transportation to SickKids.
At each hospital site, staff also practiced operating well beyond capacity and flexing their scope to improve load sharing. SickKids, for example, prepared to take on older adolescent patients, while other non-trauma sites took cases from acute hospitals to free up space for patients in need of critical care. At designated points throughout the scenario, representatives from each site attended a system-wide call to better understand the big picture, highlight any risks that were arising and focus on load balancing.
Hot debriefs, cold insights
Operation Red Card was the culmination of more than six months of planning and arose following a 2025 health and medical risk assessment conducted by Sunnybrook in preparation for the World Cup matches. Approximately 68 people worked on designing, executing and observing the exercise, including delegates from the Canadian Blood Services and Ontario Provincial Police leadership.
Immediately following the scenario, teams participated in a “hot debrief” to capture immediate reactions: what went right? What frustrations arose? Was equipment in the right locations? Were care teams able to track patients through their sites effectively? A week later, the teams then re-convened for a second debrief.
In following weeks, representatives shared insights at system-wide meetings to look at cross-centre learnings and the challenge of communicating across geographically separated care sites. Key findings were then distilled back to response teams and incorporated into Job Action Checklists (JACs) outlining roles, equipment locations, communication structures and more.
JACs and protocols can only cover so much, however. Each new trauma case brings its own unique needs that require problem-solving abilities and teamwork that can only come from well-trained staff used to working with other members of the team.
“The word for this is graceful extensibility – it speaks to people's ability to apply all their experience and wisdom in the moment to be able to solve a problem,” says Nathens.
The system that saves lives
While Toronto is no stranger to hosting large scale international events, their frequency is increasing. For example, in 2025, Taylor Swift’s record-breaking Eras Tour named Toronto as one of only two stops in Canada, drawing nearly a quarter million people into the heart of the city over the course of two weekends. A proposed expansion to Billy Bishop Airport at Toronto’s waterfront will put continuous pressure on the city, with an estimated seven- to eight-million more passengers expected to pass through the island airport each year.
As Toronto’s trauma teams prepare for more crowds from future events, risk assessments indicate a very real need to continuously train and expand on Toronto’s response network.
“There is a culmination of factors and events that drive up risk to a level where taking action to prepare is not optional,” says Judy Jung, clinical director of trauma, burn, surgery and access and flow operations at SickKids and a faculty member with the Institute of Health Policy, Management and Evaluation at the University of Toronto. “We have taken those efforts and we've taken them seriously. And each system, each hospital, each area with its own level of expertise has to stay prepared.”
Operation Red Card wasn’t the first city-wide training event. GTA Unified in 2019 brought together 34 organizations and simulated more than 300 patient injects from a series of accidents. The city’s Level I trauma centres also routinely meet through Temerty Medicine’s Trauma Program, while the de Souza Chair in Trauma Clinical Research, a joint endowment between the University of Toronto and Sunnybrook, funds training and research to improve the survivorship of trauma patients throughout the city.
But meeting the demands of Toronto’s increasing international presence will require much more in terms of research and training. Nathens has also worked to identify opportunities at Temerty Medicine and within the broader hospital network that would bring additional expertise to Toronto's response teams – but these opportunities require resourcing.
Those involved in trauma preparedness also say city-wide training events need to be held at least annually, while acute and non-acute sites across the GTA need support to prepare for major traumatic events.
That level of preparedness is what could ultimately make the difference for a successful, coordinated trauma response.
“There's a really a prolific quote from the Yonge Street van attack, that said the system saved a lot of lives that day,” says Hennebury. “It was an entire system that came together to meet the needs of those people.”
With special thanks to Jayme Paterson, Manager, Toronto Medical Planning Team for the FIFA World Cup 2026™ in Toronto at Sunnybrook Health Sciences Centre, Andrea McCormick, Director, Quality, Infection Prevention and Control (IPAC), and Emergency Preparedness at The Hospital for Sick Children, and Trish Matthews, Director, Privacy, Risk and Emergency Management at Scarborough Health Network, for insights provided for this article.
