disasters have been a part of human existence since ancient times , and so has disaster medicine . we define disaster medicine as a human response to unexpected mayhem , with the intent to limit death , disease , and injury . in recent decades , disaster medical response has largely focused on prehospital care issues such as casualty evacuation , triage , and transport , without specific emphasis on hospital management . in the united states , recent experiences with large - scale disasters have strongly reinforced the fact that hospital capacity is the major rate - limiting factor in the chain of medical response . this is especially true for critical care services and intensive care unit ( icu ) bed capacity . as we continue working to build adequate disaster medical response systems we must maintain our prehospital readiness efforts , and we must expand our focus to more precisely define the hospital and the icu as critical links in the entire response process . the purpose of the present commentary is to explore ways in which this expansion of focus might be conceived . a number of recent examples illustrate the importance of the hospital and the icu in the medical response to disaster . within a few hours of the madrid bombing explosions in march 2004 , 27 critically ill patients were admitted to the two closest hospitals , which had a maximum icu capacity of 28 beds , most of which were already occupied . after the terrorist bombing in bali , the royal darwin hospital in australia , with a capacity to care for a maximum of 12 ventilated patients , was presented with 20 critically ill patients , 15 of whom required mechanical ventilation . flooding due to heavy rain in june 2001 crippled the texas medical center in houston , and resulted in a sudden loss of 75% of the icu bed capacity for a county of 4 million people . and damage to the physical and organizational structure of the hospital may wipe out an entire critical care infrastructure . this was the case during the tokyo sarin gas subway attack in 1995 , and more recently during the severe acute respiratory syndrome outbreak in canada and asia . viewed in the context of the everyday strain on our currently available resources , the challenge is even greater . an analysis of the capacity of a 1200-bed hospital in the united states to handle patients in the setting of a toxic chemical exposure event revealed an ability to handle only two chemically contaminated patients at a time . add to this the fact that in many countries , because of efficiency and budgetary constraints , hospitals are shrinking in capacity . this has resulted in hospitals working at or near maximum capacity every day , with associated logistical concerns such as overcrowding , diversion of ambulance services , and lack of surge capacity . particularly important is the inability of emergency departments to move critically ill patients to their inpatient setting   due to the unavailability of staffed critical care beds . with future projections for a shortage of critical care physicians   and critical care nurses , these logistical barriers to icu care will persist   and will influence the provision of disaster critical care response . taken together , this means that we do not need a major disaster like a terrorist attack or an emerging infectious disease epidemic to tip the strained balance between the supply and demand of critical care resources . disasters of a local scale alone can tip the balance , such as when a fire broke out at a nightclub in rhode island in 2003 . the local hospital immediately received 40 critically - ill patients , most requiring intensive care support . education and training are effective modalities that tangibly enhance disaster medical response at every level . however , current disaster medical education programs for healthcare professionals are not coordinated in scope and content , and may not address the most pressing needs for critical care personnel . what are the imperatives that must be taught ? for example , it would be an error to assume that principles of triage , recognition of smallpox , antibiotics for anthrax , proper dosing of atropine , and so forth , represent a sufficient knowledge base . the severe acute respiratory syndrome outbreak of 2003 emphatically demonstrated that scrupulous training and execution of infection control practices became a survival skill for icu personnel . does this mean we need to build more beds , hire additional specialized personnel , or stockpile antibiotics , antidotes , and equipment against a possible disaster situation ? we think not ; this would be unworkably expensive and would still leave us incompletely prepared for many of the disaster scenarios just described . pre - emptive education is the single most effective tool we can employ to mitigate the future effects of a disaster . in terms of impact , the education of healthcare professionals is at the top of the list . the educational initiatives we propose to accomplish this goal are as follows : heightened disaster response awareness , enhanced skill sets , understanding of roles and responsibilities , alternate communication methods , self - preservation training , and experience in how to cooperate and coordinate during mayhem . medical preparedness training should not be limited to first - line treatment , but must include targeted training that covers the entire disaster medical spectrum . the challenge is distilling all of this into a curriculum that fits the very limited time availability of healthcare professionals . as one evolving example , the society of critical care medicine has developed a standardized and highly concentrated course ( fundamentals of disaster management ) to equip critical care professionals with basic but essential disaster medical knowledge . disaster response medical simulation approximating actual scenarios enables disaster planners and responders to test procedures and technologies , and to incorporate the lessons learned from past disasters . the level of realism is much higher than in facility - based exercises , where time and personnel utilization are compressed and usually do not adequately teach disaster resource management . finally , there is a useful role for what is termed ' just - in - time training ' . the intent of these programs is to make concise knowledge available to providers , at the time of an event and at the point of care . this approach is less time intensive , less labor intensive , and less cost intensive than traditional educational processes . we should point out , however , that ' just - in - time training ' serves as an adjunct , but alone it is not an adequate replacement for the other methods enumerated here . any ' just - in - time training ' program is only as effective as the skills of the professional in accessing the training when it is needed , which must be in place beforehand . experience has shown that the burden of disaster medical response largely falls to healthcare facilities proximate to an event . despite the widely held impression that ' the government will be there ' , outside help and intervention typically does not have a large impact on the initial phases of disaster medical response . we have already outlined some of the obstacles , such as strained resources or lack of communication and training , that impede cooperation . while most hospitals have plans for response to local disasters mapped out , plans that looked good on paper often go awry during execution . in terms of interfacility cooperation , given that many local hospitals financially compete with each other , teamwork in the event of a disaster is expected to materialize where it has not been previously encouraged . as such , the results are seldom efficient . a rational approach to tackle this issue includes the development of flexible and scalable plans for interchanging resources to augment the existing capacity of individual hospitals . for example , many communities currently divide disaster responsibilities according to the type and severity of injuries among the various hospitals . unfortunately , a significant percentage of casualties make their own way to the hospital , irrespective of these plans . a better way would be to build flexible surge capacity that allows hospital personnel to move from one facility to another according to need . such adaptation to circumstances will not happen spontaneously , and will require significant pre - planning . an additional example of efficient sharing is disaster medical education ; many or all of the educational proposals outlined in the previous section could be shared , increasing availability , cost - effectiveness and , probably , quality . as we have suggested , the cost of effective disaster planning is enormous . it is not realistic to expect budget - constrained facilities to absorb these additional costs , and yet relief from governments will not fill the gap . it therefore seems reasonable to seek economies of scale , such as dual - use modalities . for example , to increase icu surge capacity , consider our ability to provide critical care outside of a designated geographical location . a significant volume of critical care is provided ( nondeliberately ) every day outside the geographical constraints of an icu , hence the growing development of medical emergency teams in hospitals around the world . with little additional training , these teams could provide a highly effective adjunctive capability during disaster medical response when critical care units are full but additional icu services are required . as a second example , ensuring patient safety in the hospital is also emerging as a significant resource - consuming , but essential , activity . this is especially true as we move beyond compliance activities into multidisciplinary , tiered accident and error prevention . from this perspective , a medical catastrophe may encompass a single patient who receives improper medication through to mass casualty circumstances . while these events are fundamentally different in scope , magnitude , and cause , they share at their core a need for accurate and complete planning and education to prevent or mitigate their consequences . is there sufficient overlap to merge some of the planning , education , and practice of hospital patient safety and disaster medical response ? in summary , where we have been will not get us to where we need to go for disaster critical care response . first , we must work around apathy , confusion of purpose , and a lack of monetary resources to widen the spotlight of disaster medical response from the prehospital arena to include the hospital . we must enhance our abilities and capacity across the whole spectrum of disaster medical response . all involved organizations including hospitals , emergency medical services , fire services , police , the public health system , local municipalities and government authorities , and other health care institutions will need to integrate into a well - developed disaster educational system and response team . in the present article we have attempted to outline conceptual elements that may facilitate some of this integration . for this to happen , someone with comprehensive understanding and the necessary expertise is required nationally , regionally , and locally to provide the leadership imperative that drives integration of these disparate entities and resources . the first step is ownership , and as critical care professionals we are obliged to step forward and provide the leadership for these processes .
disaster medical response has historically focused on the pre - hospital and initial treatment needs of casualties . in particular 
 , the critical care component of many disaster response plans is incomplete . equally important , routinely available critical care resources are almost always insufficient to respond to disasters that generate anything beyond a ' modest ' casualty stream . 
 large - scale monetary funding to effectively remedy these shortfalls is unavailable . 
 education , training , and improved planning are our most effective initial steps . 
 we suggest several areas for further development , including dual usage of resources that may specifically augment critical care disaster medical capabilities over time .