When patients present in the truckloads, as they did in our trauma bay in the early morning hours of June 12, 2016, an emergency department may be inundated with ill or injured patients without notice or preparation. If that happens, teams will need to trust their instincts, their training, their experience and one another. Normal practice patterns will likely be insufficient to care for such a large surge of patients, and healthcare providers will need to turn to their ingenuity, creativity and resourcefulness to do what they think is best to care for as many patients as possible. It is also likely providers will need to make some difficult life and death decisions -- some they may not be comfortable with -- but ones they will have to live with for weeks, months or years to come.