The triage dilemma: opening Pandora's box... ever so slowly

[1] in taking on the diffi cult dilemmas surrounding triage management and training tied to surge capacity and resource allocation within intensive care settings during pandemics. Studies on triage protocols arose primarily from critical care professionals awakened to those respon sibilities during severe acute respiratory syndrome and then re-challenged during the current H1N1 pandemic [2-4]. In reality, intensive care units with their professional staff and high-tech equipment represent a major limiting factor for most communities. Th e most plausible scenario for a viral pathogen of greater severity and lethality is that emergency departments and hospital wards will be deluged with critical care patients, the challenge being how to provide 'opportunities for survival' by transferring some semblance of critical care services and expertise to these 'non-critical care' settings. Discipline-directed triage management protocols will only be as important as the manner in which these tertiary level algorithms can be integrated into a larger system-wide triage scheme that begins at the primary triage care level and ends with whatever additional resources a regional support system can mobilize. Many 'uncomfortable but real' decisions that have not, to date, been operationalized at the local level will be made. Triage management requires an infrastructure, such as health emergency operations centers (HEOCs), where central triage committees, operationalized ethical resources, palliative care guidance, data collection and analysis, and communication capacities provide high-level situational awareness for simultaneously initiating triage and modifying protocols at all health facilities and their individual triage teams [5]. While attempts to provide independent hospital-centric plans are noble, they do not solve what ultimately requires an integrated population-based system-wide solution [6]. Triage is an imperfect but necessary 'art and science' whether based on good clinical judgment or informed by protocols that attempt to direct resources to those most likely to benefi t. Critical care studies opened Pandora's box. What follows requires much more input from other disciplines and society itself. Although it may fi rst seem like one is trespassing professional boundaries, the investment in integrated preparedness and eff ective surge strategies, including system-wide triage, is crucial to minimize the need for rationing at all levels of care.