This paper examines how Stanford Hospital, a Level I trauma centre serving the metropolitan region of California's Bay Area, manages an acute surge of patients from a mass casualty incident, specifically within the context of the crowded and overburdened US emergency medicine system. The authors offer practical considerations for the rapid creation of space and bandwidth during an acute surge of injured patients as well as best practices for reorganising daily systems to care for those patients efficiently. The study also discusses how past mass casualty incidents were examined for lessons learned in order to build and refine the response plan at Stanford Hospital, with input from a multidisciplinary committee.