Disaster plans must do the greatest good for the greatest number, preserve the medical infrastructure for the sickest and most injured patients and evenly balance medical care across the entire medical spectrum of observation and acute care. Multiple venues for observation, along with limited evaluation and treatment at off-site facilities (e.g. outside the hospital) with attention to an ethical and equitable distribution system for all patients will allow for appropriate, compassionate patient and family centered treatment of individuals including the special health care needs (SHCN) patients/patients with access and functional needs, and provide quality medical care. Plans made in advance, agreements across medical and community and state entities tailored to the unique disaster and in a tiered modular surge system including observation can facilitate the most appropriate distribution and best care possible for the most patients under the difficult situation and constraints of a disaster or pandemic.