In this essay, we would like to pragmatically and realistically introduce three topics: (a) Within the hospital, critical care is acknowledged as an enormous cost driver that becomes even less manageable during a disaster response scenario. It is widely recognised that hospital critical care capabilities for large scale disaster response require significant increases, but an overarching plan to accomplish this goal is lacking. This plan necessarily includes equipment, personnel, training, and space expansion. Lesser degrees of illness and injury will likely be cared for in other venues. What is required to provide 'large scale' critical care? (b) During a true large scale disaster with a large casualty stream, the mandate is not to provide 'standard of care,' but rather 'sufficiency of care.' What is that, what does that mean to critical care and the hospital, and how is that determined? (c) Are there other mandated in-hospital requirements that can be appropriately and successfully leveraged for disaster medical response?